Application Form

APPLICATION FORM

STEP 1

NAME *

SURNAME *

EMAIL ADDRESS *

MOBILE NUMBER *

PROVINCE (SELECT): GautengWestern CapeLimpopoEastern CapeNorthern CapeNorth WestMpumalangaFree StateKwazulu Natal

TOWN *

SUBURB

STEP 2

PROPERTY TYPE *

ROOF TYPE *

NR OF BEDROOMS *

NR OF BATHROOMS *

NR OF GARAGES *

SINGLE OR DOUBLE STOREY *

PLASTER/FACEBRICK WALLS *

ESTIMATED HOUSE FLOOR SIZE *

ESTIMATED EARTH SIZE *

BUILDING STATE *

STEP 3

NR OF GEYSERS *

TYPE OF GEYSERS *

GEYSER 1 SIZE *

GEYSER 2 SIZE *

GEYSER 3 SIZE *

GEYSER 4 SIZE

GEYSER SITUATED *

KNOWN DAMAGES

SPECIFY GEYSER DAMAGE

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