Sign Up PhoneThis field is for validation purposes and should be left unchanged.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)* AddressAddress of property requiring LPG*Postal address if different from abovePreferred first delivery dateChoose Date I will advise date when required YesQuantityCylinder 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 OtherSpecial delivery instructions?Name of Gas Fitter/Company (if applicable)How did you hear about us?*CommentsProperty DetailsDo you own the property?* Yes NoIf 'no' fill out the landlord details below.If a bond is required our office will contact you.Landlord NameLandlord Phone NumberLandlord EmailLandlord AddressWould you like a comparative quote for your electricity from Contact?* Yes NoICP 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 CheckTerms & Conditions* Yes, I have read and agree to the Rockgas North Terms & Conditions
