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Account Type
Please Choose your account type*
What type of connection is this?*
Name of gasfitter doing install*
Other details*
Business Name*
Applicant Details
Name*
First Middle Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Drivers Licence Number*
DL Number Expiry Date
Name (Second applicant)*
First Middle Last
Date of Birth (Second applicant)
Date Format: DD slash MM slash YYYY
Address
Address of property requiring LPG*
Postal address if different from above
Contact Details
Mobile Number*
Home Phone Number
Email*

(For billing purposes and correspondence only)
Preferred first delivery date
Choose Preferred Date*
Date Format: 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 here
Im not ready for my first delivery, I will advise by calling the branch what date I require my delivery
- Yes
Quantity
Cylinder Size*
Cylinder Quantity*
Are there already cylinders at this property?*
Who are these cylinders supplied by?*
Other Supplier*
Other Details
Is 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 Details
Do 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 Person
Alternative Contact Name*
Alternative Contact Phone*
Alternative Contact Email*
Alternative Contact Address*
Terms & Conditions*
- Yes, I have read and agree to the Rockgas Terms & Conditions
Comments
This field is for validation purposes and should be left unchanged.