Origin | Country Energy - Natural Gas Connection Request

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

e.g. 21/05/2012 (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:

* 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:

Service address:

* 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. Gas meter is behind a fence or gate.

** Home phone:

** Work phone:

** Mobile:

Email:

* Preferred method of contact:

Postal address

Same as Service Address

** Street or PO Box:

** City / Suburb:

** Postcode:

State:

Product and service offers:

Origin and Country Energy are committed to providing you with a complete energy service so we may present you with gas, electricity, green products and household or business service offers in the future (including after your energy agreement with us ends). We will continue to provide you with these offers until you advise us otherwise. If you do not wish us to use, or enable our privacy compliant agents and contractors to use your information for this purpose, please tick the box below.

I do not wish to receive these offers in future

You agree to us sharing your personal and confidential information (including metering data) with our agents and contractors to assist us in providing you with products and services.

1. Connection date *

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

2. Do you wish to connect an existing building?

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

3. Are you an existing Country Energy customer?

* If Yes, please enter your customer number

Title:

* First Name:

Middle Name:

* Surname:

4. Customer type

* If Business, please enter:

* Trading name:

* ABN:

5. Proof of identity

* Date of birth:

* Driver's licence number:

6. Occupant status

If Tenant, please enter:

Name of owner/agent:

Address:

City / Suburb:

Phone number:

7. Address that you want to connect

Description:

Property name:

Service address:

* Street:

* City / Suburb:

* Postcode:

State:

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

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

* If Yes, what type is it?

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

* If Yes, please enter breed(s)

11. Access to gas meter

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

12. 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:

Product and service offers: