Service Request Form

Part 1: Customer Details

Energy Company

If other please specify

First Name

*required

Last Name

Mailing Address

City/Town

Post Code

Phone No. 1

*required

Phone No. 2

Part 2: Site Address & Details

ICP No.

Street No.

(Enter either Street No. or Lot & DP No. )

Lot & DP No.

(Enter either Street No. or Lot & DP No. )

Street

Suburb

City/Town

Post Code

Date Livening Required

Part 3: Electricians Details

Name

Company

Contact Phone No.

Email Address

Part 4: Connection Details

Connection Type

If other please specify

Relay

Remote Reader

Network Connection

Phase

Amps

Network Connector

Part 5: Complete

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