Customer Booking Form
Perth Electrical & Retic. Sparked By Passion, Powered By Results.
Your Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: 0000 000 000.
Email Address
*
example@example.com
The Job Address
*
Street Number & Name
Street Address Line 2
Suburb
State
Post Code
Do you reside at this job address?
Yes
No
What is your relationship to the job address
Contractor
Property Manager
Property Owner
Tenant
Other
Is this address a rental property?
Yes
No
Other
Contact Name & Mobile for access
First Name
Phone
Second Contact Name & Mobile for access
First Name
Phone
Billing Information
Billing Name
Billing Street Address
Suburb
State
Post Code
How did you hear about us?
Please briefly describe what needs sorting
Dot points work well for this section
Please upload any photos, the more the better
Browse Files
Drag and drop files here
Choose a file
The more photos you can include the better prepared we can be for your job.
Cancel
of
How urgent is the job
Not Urgent
Semi Urgent
Urgent
Which Days Best Suit Your Schedule? (you can select multiples)
Any Day
Access is good. No one needs to be home
Monday
Tuesday
Wednesday
Thursday
Friday
Other
Use this box to give any more info or details
If there is easy access, if someone needs to be home for us to attend or maybe back information around the job.
Submit
Should be Empty: