Required fields are marked with an asterisk (*) 1. Connection address Please fill in at least one of the following fields: Lot no, Unit no or Street no Lot no Unit no Street no Street name * Suburb * State * Postcode * Are there any special access restrictions, such as locked gates or dog(s)? No Yes (Please specify) Details (If Yes) 2. Your details Account number Business representative title * Business representative first name * Business representative last name * Business representative date of birth * Business name * ABN * Account PIN (nominate a 4-digit PIN to protect your account or enter your 4-digit PIN if you already have one) Phone number Mobile number Postal address (If different form supply address) State Postcode Email * Form of identification (e.g. DL, passport) * Identification number * State of issue Expiry date * 3. Additional authority on the account Title First name Last name Date of birth Form of identification (e.g. DL, passport) Identification number State of issue Expiry date Level of Authority (Enquiry only or Full access) Phone number Mobile number Postal address (If different from connection address) State Postcode 4. Acceptance Time of use tariff * By submitting this application you agree to be charged at our commercial time of use tariff for a minimum of 12 months and you agree to the installation of a meter at the connection address (if required), for which additional charges may apply. Acceptance of standard terms * You acknowledge that by submitting this application you accept the standard terms and conditions applicable to the Jacana Energy Customer Contract. Acceptance of Privacy Policy * Jacana Energy collects information to assist with the process of reviewing your application for the time of use tariff. Jacana Energy will not be able to process the application if the required information is not provided. By submitting this application, you permit us to disclose the information contained in this application to other parties (who may be overseas), including third party providers and external agencies as described in our privacy policy which is located on our website at jacanaenergy.com.au/privacy. We may also use your personal information for direct marketing purposes. Our privacy policy explains what information we collect, why we collect it and how we protect that information. Please review the Privacy Policy if you require further information about your rights to access your personal information, how to make a privacy complaint or how to opt out of receiving direct marketing. Authority to conduct credit check * By submitting this application, you authorise Jacana Energy to conduct a credit check and use any relevant information obtained about your credit history to enable Jacana Energy to establish your creditworthiness, assess your application, assist you to avoid default and assist in the collection of overdue payments. Our Privacy Policy sets out specific details relating to how we handle credit information, in particular regarding the exchange of credit information with credit reporting bodies, guarantors, debt collectors, debt buyers and other parties. Please visit the Privacy Policy for further information about the credit reporting bodies we use and how to contact them to discuss the handling of your credit information. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
