Title *

First name *

Last name *

Date of birth *

Phone number *

Postal address

Suburb

State

Postcode

Email

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

Identification number *

State of issue

Expiry date *

NT Concession Scheme card number

Lot no  

Unit no

Street no

Street name *

Suburb *

State *

Postcode *

I am requesting to transfer prepaid credit from my old address to new address?  

• Yes
• No

If yes, Meter Serial Number (old address)  

If yes, Meter Serial Number (new address)  

Proof of tenancy (OLD address) - please send to customercare@jacanaenergy.com.au, quote the lodgement number and your full name  

• Lease / rental agreement
• Other evidence from housing support organisation
• Bill / statement showing address

Proof of tenancy (NEW address) - please send to customercare@jacanaenergy.com.au, quote the lodgement number and your full name  

• Lease / rental agreement
• Other evidence from housing support organisation
• Bill / statement showing address

• 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 at www.jacanaenergy.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.