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What type of connection is this?*

Other details*

How did you hear about us?*

Name of gasfitter or contractor organising installation*

Business Sign Up

What type of connection is this?*

Other details*

Name of gasfitter or contractor organising installation*

Business Name*

Trading as*

Supply address*

Street Address Address Line 2 City ZIP / Postal Code

Is your postal address different to the address above?*

No
Yes

Postal address*

Street Address Address Line 2 City ZIP / Postal Code

Owner/managers name*

First Last

Email*

Phone*

NZBN*

GST no*

Account Contact

Name

First Last

Email*

Phone*

Site Contact

Name

First Last

Email*

Phone*

Applicant Details

Name*

First Middle Last

Date of Birth*

Mobile Number*

Home Phone Number

Email*

Photo ID (Drivers License, Passport, etc)*

Attach Photo ID*

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

Max file size 2MB.

Name (Second applicant)*

First Middle Last

Date of Birth (Second applicant)*

Mobile Phone (Second applicant)*

Home Phone (Second applicant)

Email (Second applicant)*

Photo ID (Second applicant)*

Attach Photo ID (Second applicant)*

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

Max file size 2MB.

Address

Address of property requiring LPG*

Street Address Address Line 2 City ZIP / Postal Code

Is your postal address different to the address above?*

No
Yes

Postal address

Preferred first delivery date

I will advise date when first delivery is required*

I'm waiting until my current cylinders are almost empty and I will contact Rockgas Taranaki closer to the time to place my first order.
I would like to book my first delivery in for a specific date.
New LPG installations or new builds - I will contact Rockgas Taranaki closer to the time when I have a confirmed date cylinders need to be on site.
New LPG installations or new builds - I would like to book my first delivery in for a specific date.
I have purchased/am moving into a new property please select your settlement/takeover date - please advise your settlement/takeover date.

Date*

Cylinder Information

What will the LPG be primarily used for?*

Hot water
Cooking
Heating
Forklift
Other

Cylinder Size*

Most standard installations are set up for 45KG cylinders. Why have you requested 19KG cylinders?*

How many cylinders is your LPG installation set up for?*

Most standard LPG installations are set up to take 2 x LPG cylinders. What is the reason for only requesting one?*

Are there already cylinders at this property?*

Who are these cylinders supplied by?*

Other Supplier*

Switching

If you are switching suppliers: On our first delivery we will deliver two Rockgas cylinders and will remove the cylinders currently on site from your previous supplier. We organise for them to be returned to the previous supplier depot at no cost to you.

Property Details

Is there a Dog on-site?*

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

Special delivery instructions for first delivery?

Special delivery instructions for ongoing deliveries?

Do you own the property?*

Yes
No

If 'no' fill out the landlord details below.

Payment*

I understand that for new customers there is a requirement to pay 50% of the first delivery up front.

Once your application has been processed you will receive an invoice via email to confirm the amount required.
Please contact us once this has been paid to arrange your first delivery, this will not automatically happen in our system. The remaining balance of the first delivery will be emailed and will be due for payment 20th of the following month.

Rockgas Taranaki Bank Details
Bank account Name: PJ Willcox (Taranaki) Ltd
Bank account number: 06-0793-0382212-00

Landlord Name

Landlord Phone Number

Landlord Email

Landlord Address

Have you discussed with your landlord about them paying for the cylinder rental charges?*

Yes - My landlord will be paying these charges
No - I will be paying these charges

For more information on gas bottles in relation to tenancy agreements please visit the following link: https://www.tenancy.govt.nz/rent-bond-and-bills/utilities-and-other-payments/

How would you like to pay for the cylinder rental charges?*

Yearly ($63.00 per cylinder per year)
Monthly ($7.50 per cylinder per month)

Cylinder rental charges are paid in advance.

Credit Check*

I authorise Rockgas Taranaki to obtain a Credit Check

Terms & Conditions*

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

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