First Name *

Last Name *

Company Name *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number and email address, I agree to receive text and/or email messages from the business.

Fill in the following ONLY if you are the referral partner for this contact:

Referral Partner

Referral Partner Email

Ready to upload Utility Bills?

YES

NO

Can you upload your gas bill?

YES

NO

Green Energy - Gas Bill

Once uploaded, click next.

Can you upload your water bill?

YES

NO

Green Energy - Water Bill

Once uploaded, click next.

Can you upload your power bill?

YES

NO

Green Energy - Power Bill

Once uploaded, click next.

Have you uploaded all the utility bills you have?

YES

Since you may not be ready to upload your utility bills at this time, do you wish to make an appointment with us to answer all of your questions about the Green Energy Solutions we can provide?

YES

NO

Thank you for completing the survey. Please click the "SUBMIT" button below.

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