Account TypePlease Choose your account type*Please ChooseResidential Single Account ApplicationResidential Joint Account ApplicationBusiness Account ApplicationWhat type of connection is this?*Please ChooseGetting LPG installedSwitching LPG supplierWinter Heating OnlyMoving Into A New PropertyOtherName of gasfitter doing install* Other details* Business Name* Applicant DetailsName* First Middle Last Date of Birth* DD slash MM slash YYYY Drivers Licence Number* DL Number Expiry Date Name (Second applicant)* First Middle Last Date of Birth (Second applicant) DD slash MM slash YYYY AddressAddress of property requiring LPG* Postal address if different from above Contact DetailsMobile Number*Home Phone NumberEmail* (For billing purposes and correspondence only)Preferred first delivery dateChoose Preferred Date* DD slash MM slash YYYY Please note, if we are not in your area on your preferred day, we will deliver either before or after your preferred date. View our delivery schedule hereIm not ready for my first delivery, I will advise by calling the branch what date I require my delivery Yes QuantityCylinder Size*Please Choose9kg18kg15kg Forklift19kg Forklift27kg45kgCylinder Quantity*Please Choose12345+Are there already cylinders at this property?*Please ChooseYesNoDon't knowWho are these cylinders supplied by?*Please ChooseGenesisOngasElgasRockgasOtherOther 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 Alternative Contact PersonAlternative Contact Name* Alternative Contact Phone* Alternative Contact Email* Alternative Contact Address* Terms & Conditions* Yes, I have read and agree to the Rockgas Terms & Conditions NameThis field is for validation purposes and should be left unchanged.
