Account TypePlease Choose your account type*Please ChooseSingle Account ApplicationJoint Account ApplicationBusiness Account ApplicationWhat type of connection is this?*Please ChooseSwitching supplierGetting LPG installedOtherName of gasfitter doing install*Other details*Business Name*Applicant DetailsName* First Middle Last Date of Birth Date Format: DD slash MM slash YYYY Name (Second applicant)* First Middle Last Date of Birth (Second applicant) Date Format: DD slash MM slash YYYY AddressAddress of property requiring LPG*Postal address if different from abovePreferred first delivery dateChoose Date Date Format: DD slash MM slash YYYY I will advise date when required Yes QuantityCylinder Size*Please Choose9kg18kg15kg Forklift20kg Forklift45kgCylinder Quantity*Please Choose12345678910Are there already cylinders at this property?*Please ChooseYesNoDon't knowWho are these cylinders supplied by?*Please ChooseGenesisOngasElgasOtherOther Supplier*Contact DetailsMobile Number*Home Phone NumberEmail* (For billing purposes and correspondence only)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?*CommentsProperty DetailsDo you own the property?*YesNoIf 'no' fill out the landlord details below. Landlord NameLandlord Phone NumberLandlord EmailLandlord AddressICP NumberYour ICP number is found in the top right hand corner of your power bill.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 CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
