Sign Up Residential ApplicationPlease Choose your account type*Please ChooseSingle Account ApplicationJoint Account ApplicationWhat type of connection is this?*Please ChooseSwitching supplierGetting LPG installedOtherName of gasfitter doing install* Other details* Applicant DetailsName* First Middle Last Mobile Number*Home Phone NumberEmail* Name (Second applicant)* First Middle Last Mobile Number (Second applicant)*Home Number (Second applicant)Email (Second applicant)* Date of Birth (Second applicant)* DD slash MM slash YYYY AddressAddress of property requiring LPG* Postal address if different from above Preferred first delivery dateChoose Date DD slash MM slash YYYY I will advise date when required Yes QuantityCylinder Size*Please Choose18Kg45kgCylinder Quantity*Please Choose12345678910Are there already cylinders at this property?*Please ChooseYesNoDon't knowWho are these cylinders supplied by?*Please ChooseGenesisOngasElgasOtherOther Supplier* Other DetailsWhat 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 DetailsDo 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 PersonAlternative 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 NameThis field is for validation purposes and should be left unchanged.
