Title* Select Mr Mrs Miss Ms
First Name*
Last Name*
Apartment Building & Address
Unit Number
Address of Correspondence - (If different from the apartment above)
Email Address*
Select one of the two following options regarding payment of your $30.00 (incl GST) application and administration fee (see pricing conditions at bottom of terms & conditions).
Payment By Select Cheque Added To First Account
Start Date From (Move In Date) *
Telephone Number (Day/Mobile)
Telephone Number (Night)
Are You The (Select One) Owner Tenant
Do You Want a Direct Debit Form? Yes No
Would You Like to Receive Your Statement By Email? Yes No
By submitting this application form, you confirm that the above particulars are true. You understand that we may use the information that you have provided to us for the purpose of deciding whether or not to accept your application and for purposes relating to the ongoing relationship between you and Energyco Limited (including debt recovery). You authorize us to use this information for these purposes and also to disclose it to any referee who you nominate and also to any credit reference agency we may approach. If you do not supply us with this information, which we request, we may be unable to adequately assess your financial standing, and may decline this application. We may also disclose your information to a third party to the extent required to facilitate hot water supply to you including to the operator of any gas network. You also authorize any such referee or credit reference agency to provide us with information, which we may require in order to assess your financial standing.
You have the right to request access to and correction of personal information, which we hold about you.
You acknowledge that you have read our Terms of Agreement and Pricing List on the reverse of this Application Form and agree to be bound by the terms and conditions.
