Account TypePlease Choose your account type*Please ChooseSingle Account ApplicationJoint Account ApplicationBusiness Account ApplicationWhat type of connection is this?*Please ChooseSwitching supplierGetting LPG installedOtherName of gasfitter doing install*Other details*Business Name*Applicant DetailsName* First Middle Last Mobile Number*Home Phone NumberEmail* Date of Birth* Date Format: DD slash MM slash YYYY Photo ID*Please ChooseI'll upload nowI'll send it later to email@example.comAttach Photo ID*Max file size 2MB.Name (Second applicant)* First Middle Last Mobile Number (Second applicant)*Home Number (Second applicant)Email (Second applicant)* Date of Birth (Second applicant)* Date Format: DD slash MM slash YYYY Photo ID (Second applicant)*Please ChooseI'll upload nowI'll send it later to firstname.lastname@example.orgAttach Photo ID (Second applicant)*Max file size 2MB.AddressAddress of property requiring LPG*Postal address if different from abovePreferred first delivery dateChoose Date Date Format: DD slash MM slash YYYY I will advise date when required Yes QuantityCylinder Size*Please Choose9kg18kg15kg Forklift20kg Forklift45kgCylinder Quantity*Please Choose12345678910Are there already cylinders at this property?*Please ChooseYesNoDon't knowWho are these cylinders supplied by?*Please ChooseGenesisOngasElgasOtherOther Supplier*Other DetailsIs there a Dog on-site?*Are there any site access issues that we need to be aware of ?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?*CommentsProperty DetailsDo you own the property?*YesNoIf '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?*YesNoICP Number*Your ICP number is found in the top right hand corner of your power bill.Alternative Contact PersonAlternative Contact Name*Alternative Contact Phone*Alternative Contact Email*Alternative Contact Address*Credit Check* I authorise Rockgas Taranaki to obtain a Credit Check Terms & Conditions* Yes, I have read and agree to the Rockgas Terms & Conditions NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.