Acknowledgement Form -

Heat Pump Installation Acknowledgement Form

Please fill out the details below to confirm and acknowledge the installation of heat pump(s) at your business property.

Name

Please enter your full name.

This field is required.

Please enter your email address for confirmation.

This field is required.

Contact Number

Please enter your contact number.

This field is required.

Number of Heat Pump

Please specify the number of heat pumps installed.

This field is required.

Purpose

Please describe the purpose of the heat pump installation.

This field is required.

Existing Heat Pump

Provide details if there is an existing heat pump.

This field is required.

Business Name

Please enter your business name.

This field is required.

Business Address

Please provide your business address.

Address Line 1

This field is required.

Address Line 2

This field is required.

City

This field is required.

State

This field is required.

Postal Code

This field is required.

Country

ABN (optional)

Please enter your Australian Business Number (if applicable).

This field is required.

I agree that installing the heat pump(s) will support and benefit my business operations.

This field is required.

I confirm the hot water from the installed heat pump will be used strictly for business purposes.

This field is required.

I confirm there are no residential units or living quarters on the property.

This field is required.

I confirm I do not plan to remove or change any part of the installed heat pump.

This field is required.

I understand and accept that the heat pump operates up to 65 degrees.

This field is required.

I agree to pay $200 per tank installed and understand this payment is non-refundable.

This field is required.