Please fill in at least one of the following fields: Lot no, Unit no or Street no

Lot no

Unit no

Street no

Street name *

Suburb *

State *

Postcode *

Requested disconnection date *

Address to send your final bill

Street address / PO Box *

Suburb *

State *

Postcode *

Please fill in at least one of the following fields: Lot no, Unit no or Street no

Lot no  

Unit no

Street no

Street name *

Suburb *

State *

Postcode *

Requested connection date *

Does the property have solar panels*

• Yes
• No
• Unsure

If yes, please complete a Power Purchase Agreement

Account number (if existing customer)

Title *

Business Representative First name *

Business Representative Last name *

Business Representative Date of birth *

Business name *

ABN (please provide ABN certificate with your application) *

Are you a Public Benevolent Institution registered with the ACNC? (Please send us a copy of your PBI registration)

• Yes

Account PIN (nominate a 4-digit PIN to protect your account or enter your 4-digit PIN if you already have one)

Phone number

Mobile number

Postal address*

Suburb

State

Postcode

Email *

Preferred delivery method (bills and correspondence)

• Email
• Post

Business Representative form of identification (DL, Passport etc.)*

Identification number *

State of issue

Expiry date *

Title

First name

Last name

Date of birth

Form of identification (e.g. DL, passport)

Identification number

State of issue

Expiry date

Level of authority (Enquiry only)

Phone number

Mobile number

Postal address (if different)

State

Postcode

Email

• Acceptance of standard terms

You acknowledge that by submitting this application you accept the standard terms and conditions applicable to the Jacana Energy Customer Contract (available from a Power and Water Customer Service Centre or at jacananenergy.com.au/contract).

• Acceptance of Privacy Policy

Jacana Energy collects information to assist with the process of reviewing this application to connect, disconnect or alter a service. Jacana Energy will not be able to process the application if the required information is not provided. By submitting this application, you permit us to disclose the information contained in this application to other parties (who may be overseas), including third party providers and external agencies as described in our privacy policy which is located on our website at jacanaenergy.com.au/privacy. We may also use your personal information for direct marketing purposes. Our privacy policy explains what information we collect, why we collect it and how we protect that information. Please review the Privacy Policy if you require further information about your rights to access your personal information, how to make a privacy complaint or how to opt out of receiving direct marketing.

• Authority to conduct credit check

By submitting this application, you authorise Jacana Energy to conduct a credit check and use any relevant information obtained about your credit history to enable Jacana Energy to establish your creditworthiness, assess your application, assist you to avoid default and assist in the collection of overdue payments. Our Privacy Policy sets out specific details relating to how we handle credit information, in particular regarding the exchange of credit information with credit reporting bodies, guarantors, debt collectors, debt buyers and other parties. Please visit the Privacy Policy on our website for further information about the credit reporting bodies we use and how to contact them to discuss the handling of your credit information.