Origin | Country Energy - Electricity Connection Request

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

e.g. 21/05/2012 (dd/mm/yyyy)

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 portion of your electricity consumption matched into the grid with electricity from renewable sources.

Domestic or Rural Customers

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

Business Customers

Product *	Price (incl. GST)	GreenPower kWh's	Please select
countrygreen® energy - business 10%	Additional 1.43 cent per kWh	10% of your electricity consumption	Yes
countrygreen® energy - business 100%	Additional 7.15 cent per kWh	100% of your electricity consumption	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:

** 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:

** 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

** 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. Sign up to countrygreen® ?

Domestic or Rural Customers

Business Customers

6. Proof of identity

* Date of birth:

* Driver's licence number:

7. Occupant status

If Tenant, please enter:

Name of owner/agent:

Address:

City / Suburb:

Phone number:

8. Address that you want to connect

Description:

Property name:

National Metering Identifier:

** NMI:

And / Or

Service address:

** Street:

** City / Suburb:

** Postcode:

State:

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

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

* If Yes, what type is it?

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

* If Yes, please enter breed(s)

12. 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.

13. 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: