My Company / Business Details Business Name * Contact Name * Company Number * Email * Phone (daytime) * Phone (afterhours) *

Premises for Delivery / Connection

Prefix Prefix No Street Number * Address * Suburb / City * Postcode *

Address for gas delivery *

You are *

Owner/Occupier

Tenant

Please indicate the uses for which you require gas:

Heating

Cooking

Hot Water

Forklift

Other (please specify)

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