LED Upgrade Eligibility Form

1
Do you have any of these old lights?* This field is required.(Select ALL that apply)
Highbays
Halogen Floodlights
Fluorescent fittings
Other
2
Approximately how many Highbays do you have?
3
Approximately how many Halogen Floodlights do you have?
4
Approximately how many Fluorescent fittings do you have?
5
Add a photo/s of the "Other" lights hereAdd as many photos as you like
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
6
Approximately how many of these lights do you have?If you have added multiple images, you can elaborate below if you like.
Huge
Large
Normal
Small
Ok
Ok
7
Do you have any other lights that you may want replaced?* This field is required.
YESNO
8
Add a photo/s of the other lights hereAdd as many photos as you like
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
9
Approximately how many of these lights do you have?If you have added multiple images, you can elaborate below if you like.
Huge
Large
Normal
Small
Ok
Ok
10
OK, we're almost done! Can I grab your name?* This field is required.
11
Thanks {name}, what's the name of the business?* This field is required.
12
And what suburb is {businessname} in {name}?* This field is required.
13
And your best Email {name}?* This field is required.
example@example.com
14
And finally, just your best phone number?* This field is required.(your info is safe with us!)
Should be Empty: