Go Green, Be Green

First Name:

Last Name:

Partners Name:

Address:

Address line 2

Suburb:

State: Please select... ACT NSW NT QLD SA TAS VIC WA Other

Postcode:

Email:

Confirm Email:

Assessor Name: (leave blank if unknown)

Home Phone:

Mobile:

Number of Adults in House:

Number of children in House:

Age of eldest Child:

Please list two dates you are available at home for around 1 hour to enable our assessor to complete the report

Date 1:

Date 2:

1. I am an Australian citizen or permanent resident of Australia.
2. I am aged 18 or over.
3. I have a taxable income no greater than $250,000 per annum.
4. I am either an owner of the Home or trustee of the Home (as shown On the current Title) or listed on the current lease of the Home.
5. My Home meets the following criteria:
   1. a) The Home is not a government owned dwelling:
   2. b) The Home is not owned by a corporate organisation or company, Other than an Australian Registered Charity.
6. If the Home is owned by an Australian Registered Charity, I have full legal Authority to apply for the Program on behalf of the Australian Registered Charity.