First Name*

Last Name*

Phone Number:*

Phone Type*
CellHomeWork
Email*

Address Line 1*

Address Line 2

City*

State*
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code*

What type of home do you live in?*
---Single Family DwellingTownhouse/Row HouseVertically Split/ Duplex/TriplexApartment /CondominiumMobile/Prefabricated HomeOther
Do you own your home?*
YesNo
Language Preference:*
---EnglishSpanish

Age of roof (in years)
---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.