Account TypeWould you like this account to be billed to:*Please ChooseYour name onlyJoint names with someoneBusiness/Company/Trust nameWhat type of connection is this?*Please ChooseSwitching supplierMoving into a property with existing LPG connectionGetting LPG installedNew BuildOtherIs this for residential or business usage?*Please chooseResidential usageBusiness usageName of Company & Gasfitter doing installation* Other details* Business Name* Applicant DetailsName* First Middle Last Name* First Middle Last Mobile Number*Home Phone NumberEmail* Date of Birth* DD slash MM slash YYYY Photo ID (Drivers License, Passport, etc)*Please ChooseI'll upload nowI'll send it later to email@example.comAttach Photo ID*Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.Max file size 2MB.Name (Second applicant)* First Middle Last Mobile Phone (Second applicant)*Home Phone (Second applicant)Email (Second applicant)* Date of Birth (Second applicant)* DD slash MM slash YYYY Photo ID (Second applicant)*Please ChooseI'll upload nowI'll send it later to firstname.lastname@example.orgAttach Photo ID (Second applicant)*Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.Max file size 2MB.AddressAddress of property requiring LPG* City* Postal address if different from above Preferred first delivery dateChoose Date DD slash MM slash YYYY I will advise date when required Yes QuantityCylinder Size*Please Choose9kg19kg15kg Forklift19kg Forklift45kg (Standard House Bottle Size)Cylinder Quantity*Please Choose12345678910Are there already cylinders at this property?*Please ChooseYesNoDon't knowWho are these cylinders supplied by?*Please ChooseRockgasGenesisOngasElgasOtherOther Supplier* Other DetailsIs there a Dog on-site?* Are there any site access issues that we need to be aware of ? What will the LPG be primarily used for? Hot water Cooking Heating Forklift Other Other Primary Use* Special delivery instructions? How did you hear about us?* Comments Property DetailsDo you own the property?* Yes No If 'no' fill out the landlord details below. Landlord Name Landlord Phone Number Landlord Email Landlord Address Would you like a comparative quote for your electricity from Contact?* Yes No ICP Number* Your ICP number is found in the top right hand corner of your power bill.Credit Check* I authorise Rockgas Wanganui to obtain a Credit Check Terms & Conditions* Yes, I have read and agree to the Rockgas Terms & Conditions PhoneThis field is for validation purposes and should be left unchanged.