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Application Type
Please Choose your application type
*
Please Choose
Single Application
Joint Application
Business Application
What type of connection is this?
*
Please Choose
Switching supplier
Getting LPG installed
Moving house
Other
What company are you switching from?
*
Business Name
*
Applicant Details
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Title
First
Middle
Last
Mobile Number
*
Home Phone Number
Email
*
Date of Birth
DD slash MM slash YYYY
Name (Second applicant)
*
Mr.
Mrs.
Miss
Ms.
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
Address
Address of property requiring LPG
*
Postal address if different from above
Quantity
Cylinder Size
*
Please Select
9kg
18kg
15kg Forklift
20kg Forklift
45kg
Cylinder Quantity
*
1
2
3
4
5
6
7
8
9
10
Cylinders at this property already?
*
Please Choose
Yes
No
Don't know
Preferred first delivery date
*
DD slash MM slash YYYY
Other Details
Is there a Dog on-site?
Are there any site access issues that we need to be aware of ?
Property Details
Do 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?
*
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Yes Please
No Thanks
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