First Name* Last Name* Phone Number:* Phone Type* CellHomeWork Email*
Address Line 1* Address Line 2 City* State* —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code*
What type of home do you live in?* —Please choose an option—Single Family DwellingTownhouse/Row HouseVertically Split/ Duplex/TriplexApartment /CondominiumMobile/Prefabricated HomeOther Do you own your home?* YesNo Language Preference:* —Please choose an option—EnglishSpanishOther
Age of roof (in years) —Please choose an option—0-1515-3030 plus All owners/mortgage holders are aware of this assessment request* YesNo Average Electric Bill over last 6 months Current electricity cost per kilowatt Tell me about zero upfront cost options
I agree with the following Terms and Authorizations:* I certify that I am the Customer listed on the Referral Form and that I have personally provided and verified all the information required. I agree and authorize SolarSynergy.me to share my personal information with the “one” solar energy provider it finds as a match for my specific home location. I understand that SolarSynergy.me will notify me, via email, the name of the solar provider prior to being contacted. I expect that information to be shared within 24-hours of submission of this request. I certify that I have not entered into a solar energy contract within the last 6 months. I authorize the soon to be named SolarSynergy.me partner to call me and send pre-recorded messages and text messages about products and services at the telephone number I entered above, using an auto-dialer, even if I am on a national or state “Do Not Call” list. Message and data rates apply. I understand that consent here is not a condition of purchase. I understand all promotions and rewards are managed through SolarSynergy.me exclusively, and not its partners.
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