Account number (if existing customer)

First name *

Middle name *

Last name *

Date of birth *

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

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

Identification number *

State of issue

Expiry date *

NT Concession Scheme card number (issued by Territory Families)

Level of authority

• Enquiry only: customer can make changes to the account but is not responsible for the account. (complete part A)
• Financially responsible: customer has full access to the account and responsibility for paying the account. (Complete Part A and B)

For more information about authorities, visit the Additional authority page.

Part A

First name

Last name

Date of birth

Phone number

Mobile number

Email

Part B

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

Identification number

State of issue

Expiry date

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 *

If there are access restrictions to your property such as locked gates or dogs, the disconnection will not take place and you will be liable for usage and supply charges until access is granted.

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 *

If there are access restrictions to your property such as locked gates or dogs, the connection will not take place.

Does the property have solar panels?*

• Yes
• No
• Unsure

By submitting this application, you:

• Accept the standard terms and conditions applicable to the Jacana Energy Customer Contract - available at www.jacanaenergy.com.au/contract.

• Consent to Jacana Energy’s use, holding and disclosure of your personal and credit information in accordance with our privacy and credit reporting policies, available at www.jacanaenergy.com.au/privacy. Our credit reporting policy explains who we disclose credit information to and how this could affect your credit worthiness, as well as how you can access your credit information, request a correction and make a complaint.

• Consent to being contacted by Jacana Energy about offers for our products and services. Our privacy policy has information about how you can opt out of receiving direct marketing.