Country Energy - Energy Connection Request

* Select the type of energy you want to connect. (You can select both)

Electricity
*Gas

Must be a business day. Please allow at least two business days notice.

e.g. 11/02/2010 (dd/mm/yyyy)

*Gas:Due to supply and installation requirements, connection to gas may take longer than two business days. An existing Natural Gas Network in your area may also be required. One of our customer service staff will contact you to discuss your gas connection request.

Yes
No

* If No, please enter details of the location and requirements:

Yes
No

* If Yes, please enter your customer number

If No, please enter:

Title:

* First Name:

Middle Name:

* Surname:

Domestic
Rural
Business

* If Business, please enter:

* Trading name:

* ABN:

By signing up to countrygreen®, you can choose to have a percentage of your energy sourced from renewable sources from an additional $1.00 per week including GST.

Sign up to countrygreen® now?
Yes
No

Domestic or Rural Customers

Product *	Price (incl. GST)	Accreditation	GreenPower kWh's	Please select
countrygreen® 100%	$8.00 extra per week	100%	6,470 kWh's	Yes
countrygreen® 50%	$4.50 extra per week	50%	3,235 kWh's	Yes
countrygreen® 20%	$2.00 extra per week	20%	1,294 kwh	Yes
countrygreen® 10%	$1.30 extra per week	10%	647 kWh's	Yes

Business Customers

Product *	Price (incl. GST)	Accreditation	GreenPower kWh's	Please select
countrygreen® energy - business 10%	Additional 1.43 cent per kWh	10%	Consumption based	Yes
countrygreen® energy - business 100%	Additional 7.15 cent per kWh	100%	Consumption based	Yes

By signing up to the product of your choice, the respective amount of renewable energy shown in the table above will be purchased on your behalf.

* Date of birth:

e.g. 26/09/1986 (dd/mm/yyyy)

* Driver's licence number:

Or a password you nominate.

Tenant
Owner

If Tenant, please enter:

Name of owner/agent:

Address:

City / Suburb:

Phone number:

Description:

Property name:

National Metering Identifier: For electricity connection only

** NMI:

Note: The NMI number for the premises will be shown on a recent bill for that premises. It uniquely identifies your premises in the national electricity market. If you do not have that information, please complete the Service address box.

And / Or

Service address: For electricity or gas connection

** Street:

** City / Suburb:

** Postcode:

State:

Yes
No

If Yes, click here to access the relevant concession information.

Yes
No

* If Yes, what type is it?

Yes
No

* If Yes, please enter breed(s)

Is there any issue that the meter reader should be aware of? e.g. Meter box behind a fence or gate.

** Home phone:

** Work phone:

** Mobile:

Email:

* Preferred method of contact:

Postal address

Same as Service Address

1. Type of connection(s)

* Select the type of energy you want to connect. (You can select both)

2. Connection date *

Must be a business day. Please allow at least two business days notice.

3. Do you wish to connect an existing building?

* If No, please enter details of the location and requirements:

4. Are you an existing Country Energy customer?

* If Yes, please enter your customer number

Title:

* First Name:

Middle Name:

* Surname:

5. Customer type

* If Business, please enter:

* Trading name:

* ABN:

6. Sign up to countrygreen® ?

Domestic or Rural Customers

Business Customers

7. Proof of identity

* Date of birth:

* Driver's licence number:

8. Occupant status

If Tenant, please enter:

Name of owner/agent:

Address:

City / Suburb:

Phone number:

9. Address that you want to connect

Description:

Property name:

National Metering Identifier: For electricity connection only

** NMI:

And / Or

Service address: For electricity or gas connection

** Street:

** City / Suburb:

** Postcode:

State:

10. Do you have a pensioner or veteran's card?

11. Do you have a life support system at the service address?

* If Yes, what type is it?

12. Do you have a dog or dogs at the service address?

* If Yes, please enter breed(s)

13. Access to meter box

Is there any issue that the meter reader should be aware of? e.g. Meter box behind a fence or gate.

14. Please enter your contact details

** Home phone:

** Work phone:

** Mobile:

Email:

* Preferred method of contact:

Postal address

** Street or PO Box:

** City / Suburb:

** Postcode:

State: