Application TypePlease Choose your application type*Please ChooseSingle ApplicationJoint ApplicationBusiness ApplicationWhat type of connection is this?*Please ChooseSwitching supplierGetting LPG installedMoving houseOtherWhat company are you switching from?* Business Name* Applicant DetailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Middle Last Mobile Number*Home Phone NumberEmail* Date of Birth DD slash MM slash YYYY Name (Second applicant)* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Middle Last Mobile Phone (Second applicant)*Home Phone (Second applicant)Email (Second applicant)* Date of Birth (Second applicant) DD slash MM slash YYYY AddressAddress of property requiring LPG* Postal address if different from above QuantityCylinder Size*Please Select9kg18kg15kg Forklift20kg Forklift45kgCylinder Quantity*12345678910Cylinders at this property already?*Please ChooseYesNoDon't knowPreferred first delivery date* DD slash MM slash YYYY Other DetailsIs there a Dog on-site?Are there any site access issues that we need to be aware of ?Property DetailsDo you own the property?* Yes No If 'no' fill out the landlord details below. If a bond is required our office will contact you.Landlord Name Landlord Phone Number What will the LPG be used for?* Hot Water Heating Cooking Commercial Forklift Other Special delivery instructions? Who is your current electricity supplier? Name of Gas Fitter/Company (if applicable) Would you like a competitive quote from Contact Energy for your electricity?*Please ChooseYes PleaseNo ThanksHow did you hear about us?CommentsCredit Check* I authorise Rockgas to obtain a Credit Check Terms & Conditions* Yes, I have read and agree to the Rockgas Terms & Conditions EmailThis field is for validation purposes and should be left unchanged.