Application for electricity connection / disconnection Residential

Use this form if you are a residential customer and you are applying for:

Connection of electricity: You want to get electricity connected at your home address.
Disconnection of electricity: You want your electricity disconnected, but do not require reconnection at a new address.
Move-out/Move-in: You are moving and want to disconnect electricity at your old address and reconnect at your new address.

Required fields are marked with an asterisk (*)

1. What service do you require ?

Select one of these three options: *

Connection

Disconnection

Move-out/Move-in

Is the Connecting property used for residential or commercial purposes?

Residential

Commercial

Both

(e.g. residential with home business)

Connections and disconnection may take up to 7 business days to be processed.

If your request is URGENT continue to complete the online form with the next available date and call and provide your reference number with your amended date to prioritise your service request.

Connection and disconnection fees apply. For information visit the Pricing and Tariffs page.

2. Your details

Account number (if existing customer)

First name

Middle name

Last name

Date of birth

Phone number

Mobile number

Postal address

Suburb

State

Postcode

Preferred delivery method (bills and correspondence)

Post

Form of identification

Drivers Licence

Passport

Proof of Age Card

ImmiCard

If you don't have any of these forms of ID, please contact us on 1800 522 262 for further assistance.

Identification number

State of issue

Expiry date

NT Concession Scheme card number (issued by Territory Families)

The name on the concession card must match the name of the Jacana Energy account holder.

Business name

ABN

GST registered?

Yes

Goods and services tax registration status

Are you a Public Benevolent Institution registered with the ACNC?

Yes

Account PIN (nominate a 4-digit PIN to protect your account or enter your 4-digit PIN if you already have one)

Please enter no more than 4 characters.

3. Additional authority on the account

Would you like to add an additional authority on to the account?

Yes

Level of authority

Enquiry only contact: customer can request information about the account and make a payment, but can't request any financial transaction on the account. (complete part A)

Financially responsible contact: gives the customer the same access as the account holder, except the ability to establish power. This contact is not responsible for any debt on the account. (Complete Part A and B)

Part A

First name

Last name

Date of birth

Phone number

Mobile number

Part B

Form of identification (e.g. DL, passport)

Identification number

State of issue

Expiry date

4. Disconnection address

Lot no

Unit no

Street no

Street name

Suburb

State

Postcode

Requested disconnection date

Jacana Energy does not schedule disconnection services during weekends or public holidays. If you select a public holiday or a weekend, your request will be scheduled for the next business day. If your request is needed in the next 7 business days, please call us at 1800 522 262.

Additional access instructions

Please note: Instructions will be taken into consideration but not guaranteed.

If there are access restrictions to your property such as locked gates or unrestrained dogs, the disconnection will not take place and you will be liable for usage and supply charges until access is granted.

Postal address where to send your final bill

Note: We will attempt to send your final bill by email first if you have selected this option as your preferred delivery method; however please also provide a postal address to forward any future Jacana Energy mail.

Street address / PO Box

Suburb

State

Postcode

Please fill in at least one of the following fields: Lot no, Unit no or Street no.

5. Connection address

Please provide the meter number (if known)

Is the property a newly built home?

Yes

I don't know

Lot no

(Mandatory for new developments / newly built homes)

Unit no

Street no

Street name

Suburb

State

Postcode

Requested connection date

Jacana Energy does not schedule connection services during weekends or public holidays. If you select a public holiday or a weekend, your request will be scheduled for the next business day. If your request is needed in the next 7 business days, please call us at 1800 522 262.

Additional access instructions

Please note: Instructions will be taken into consideration but not guaranteed.

If there are access restrictions to your property such as locked gates or unrestrained dogs, the connection will not take place. You may still be charged a contractor call out fee.

Does the property have solar panels?

Yes

Unsure

Will anyone living at this address use an electrical device that assists with a life-threatening medical condition? (Life support)

Yes

By selecting YES, you confirm that someone living (or will live) in this property has a life-threatening condition that requires uninterrupted electricity supply to operate equipment a registered medical practitioner certifies is needed for life support.

Click here for full details.

You will be listed temporarily on our Life Support Customer Register. We will send you a Medical Confirmation Form or you can download it here. The form needs to be signed by your medical practitioner and returned to us no later than 21 business days from when you receive it.

Failure to provide a completed Medical Confirmation Form may result in your service address being delisted from the Life Support Customer Register.

5-B. Life Support Details

Patient's Name

Relationship with account holder

Patient(s) contact number

Emergency contact(s) name

Emergency contact(s) number

Emergency contact email address

Patient(s) email address

If different to account holder

Emergency contact address

Date life support equipment required from

Must be on or after connection date.

Type of life support equipment:

Oxygen concentrator

Intermittent peritoneal dialysis machine

Kidney dialysis machine

Chronic positive airways pressure respirator

Crigler-Najjar syndrome phototherapy equipment

Ventilator for life support

Other (Please specify in notes)

Additional notes

6. Acceptance

By submitting this application, you:

Accept the standard terms and conditions applicable to the Jacana Energy Customer Contract.

Please fill in our business Move In/Move Out form.

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