Title
First Name Daytime Phone
( )
Last Name
( )
Date of Birth
Tick for preferred
billing address
Email Address
Number
Title
First Name Daytime Phone
( )
Last Name
( )
Date of Birth
Tick for preferred
billing address
Email Address
Number
Daytime Phone
( )
( )
Last Name Email Address
State Post Code State Post Code
Relationship
ELECTRICITY
By signing this document you:
Signed on behalf of Metered Energy by:
Move In Date
Print Name Print Name
Today's Date Today's Date
Previous Address (if at current address less than 3 years)
Supply Address
(Premises)
Postal Address (if
different from Supply
Address)
ENERGY SUPPLY DETAILS (Office Use Only)
Pensioner Concession
Repartiation Health Card
Owner Tenant
Australian Drivers Licence No.
Or Passport No.
Owner Tenant
Contact Number
THE AGREEMENT IS SUBJECT TO A COOLING OFF PERIOD OF 10 BUSINESS DAYS.
CUSTOMER ACKNOWLEDGEMENT & ACCEPTANCE
c. Authorise us to collect, maintain, use and disclose your personal information in the manner set out in the Privacy Statement contained in the Energy Agreement
(including obtaining a credit report)
a. Acknowledge that you have been provided with a copy of the Disclosure Statement contained in the Energy Agreement;
Meter Number
Meter Number
b. And agree to the terms and conditions contained therin.
APPLICATION (The Schedule)
CUSTOMER DETAILS (PLEASE USE BLOCK LETTERS) If the account will be in two names, please complete Customer 1 and Customer 2 details.
Australian Drivers Licence No.
Or Passport No.
State of issue
Country of issue
RESIDENTIAL TENANT 1
RESIDENTIAL TENANT 2 (Optional)
COMPANY
State of issue
Country of issue
Owner Tenant
Pensioner Concession
Repartiation Health Card
ADDRESS DETAILS
First Name
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signature
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signature
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signature
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