Jacana Energy|

Use this form if you are a business requesting a payment arrangement.

Information received via this online form is processed during business hours, Monday to Friday, 8:00am to 4:30pm.

Required fields are marked with an asterisk (*)

Your details

Account number

Company name *

Trading name

ABN / ACN *

Representative first name *

Representative last name *

Phone number *

Email address *

Service address *

Payment arrangement details

Are you able to make an initial payment against your current bill? *

If yes, what amount can you afford to pay now?

After that, what is the maximum amount you can afford to pay and at what frequency? *

Select frequency *

When would you like your payment arrangement to start (dd/mm/yy)? *

Do you agree to Jacana Energy calculating the duration of your payment arrangement based on what you can afford to pay? *

Your current situation

Is your business still trading? *

If yes, what capacity are you still trading at(%)? *

Have you applied for a government stimulus payment? *

Any further information you would like to provide?

Acceptances

By submitting this form you agree to the following terms:

I confirm that the information provided in this form is true and accurate.

I give permission to Jacana Energy to set-up a payment arrangement for my account based on the information submitted in this form.

I understand that my payment arrangement can be varied as required and I agree to notify Jacana Energy immediately if my circumstances change.

CAPTCHA

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