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Authorised Person Details

Title

First Name

Last Name

Phone Number

Email Address

Date of Birth

Business Name

Trading Name

Contract Term (Years)

Contract Start Date

ABN

Supply Address

Street Address

Address Line 2

City

State

PostalCode

I have a different postal address

Postal address

Street Address

Address Line 2

City

State

PostalCode

Identification type provided

Identification number

NMI

( Find this on your current providers bill, ignore if you are just moving in )

Move in / Activation Date

Life Support Customer?

Is this Customer the Registration Owner?

Life Support Date

Life Support Equipment

Life Support Notes

Is the Life Support contact the same as the Authorised Person Details above?

Title

First Name

Last Name

Phone Number

Email Address

Is the postal address the same as the Supply Address noted above?

Street Address

Address Line 2

City

State

PostalCode

Eligible for concessions?

(By ticking the above box you authorise Electricityinabox Pty Ltd to use Centrelink Confirmation eServices to perform a Centrelink/DVA enquiry of your Centrelink or Department of Veterans’ Affairs Customer details and concession card status in order to enable the organisation to determine if you qualify for a concession.

You also give consent for the Australian Government Department of Human Services (the department) to provide the results of that enquiry to Electricityinabox Pty Ltd.

You understand that the department will use information you have provided to Electricityinabox Pty Ltd to confirm your eligibility for relevant concession and will disclose to Electricityinabox Pty Ltd, personal information including your name, address and concession card type and status.)

Concession Card First Name

Concession Card Last Name

Concession Card Type

Concession Card Number

Concession Card Start Date

Concession Card Expiry Date

Do you understand the above as it has been explained to you?

I understand and agree to transfer my energy retail plan from my current retail supplier to Electricityinabox?

I have read and accept terms and conditions

Tell us about your property

Authorised Person Details

Supply Address

Postal address

Dial 1300 933 039

Hardship line 03 9007 0977