Account TypePlease Choose your account type*Please ChooseSingle Account ApplicationJoint Account ApplicationBusiness Account ApplicationWhat type of connection is this?*Please ChooseSwitching supplierGetting LPG installedMoving into a property with existing LPG connectionsOtherName of Company and Gasfitter doing installation (if applicable)* Other details* Business Name* Applicant DetailsName* First Middle Last Mobile Number*Home Phone NumberEmail* Date of Birth* DD slash MM slash YYYY Photo ID (Drivers License, Passport, etc)*Please ChooseI'll upload nowI'll send it later to sales@rockgastaranaki.co.nzAttach Photo ID*Max. file size: 64 MB.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)* DD slash MM slash YYYY Photo ID (Second applicant)*Please ChooseI'll upload nowI'll send it later to admin@rockgastaranaki.co.nzAttach Photo ID (Second applicant)*Max. file size: 64 MB.Max file size 2MB.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 Choose9kg18kg15kg Forklift20kg Forklift45kg (Standard House Bottle Size)Cylinder 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 Company & Gasfitter doing installation 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.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 EmailThis field is for validation purposes and should be left unchanged.
