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Residential Application

Please Choose your account type*

What type of connection is this?*

Name of gasfitter doing install*

Other details*

Applicant Details

Name*

First Middle Last

Mobile Number*

Home Phone Number

Email*

Name (Second applicant)*

First Middle Last

Mobile Number (Second applicant)*

Home Number (Second applicant)

Email (Second applicant)*

Date of Birth (Second applicant)*

Address

Address of property requiring LPG*

Postal address if different from above

Preferred first delivery date

Choose Date

I will advise date when required

Yes

Quantity

Cylinder Size*

Cylinder Quantity*

Are there already cylinders at this property?*

Who are these cylinders supplied by?*

Other Supplier*

Other Details

What will LPG be primarily used for?*

Hot water
Cooking
Heating
Other

Special delivery instructions?

Name of Gas Fitter/Company (if applicable)

How did you hear about us?*

Comments

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

Landlord Email

Landlord Address

Would you like a comparative quote for your electricity from Contact?*

Yes
No

ICP Number*

Your ICP number is found in the top right hand corner of your power bill.

Is there a Dog on-site?*

Are there any site access issues that we need to be aware of ?

Alternative Contact Person

Alternative Contact Name*

Alternative Contact Phone*

Alternative Contact Email*

Alternative Contact Address*

Credit Check*

I authorise Rockgas North to obtain a Credit Check

Terms & Conditions*

Yes, I have read and agree to the Rockgas North Terms & Conditions

Email

This field is for validation purposes and should be left unchanged.

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