Use this form if you are a business requesting a payment arrangement. Information received via this online form is processed during business hours, Monday to Friday, 8:00am to 4:30pm. Required fields are marked with an asterisk (*) Your details Account number Company name * Trading name ABN / ACN * Representative first name * Representative last name * Phone number * Email address * Service address * Payment arrangement details Are you able to make an initial payment against your current bill? * -- Please Select --YesNo If yes, what amount can you afford to pay now? After that, what is the maximum amount you can afford to pay and at what frequency? * Select frequency * -- Please Select --WeeklyFortnightly When would you like your payment arrangement to start (dd/mm/yy)? * Do you agree to Jacana Energy calculating the duration of your payment arrangement based on what you can afford to pay? * -- Please Select --YesNo Your current situation Is your business still trading? * -- Please Select --YesNo If yes, what capacity are you still trading at(%)? * Have you applied for a government stimulus payment? * -- Please Select --YesNo Any further information you would like to provide? Acceptances By submitting this form you agree to the following terms: I confirm that the information provided in this form is true and accurate. * I confirm that the information provided in this form is true and accurate. I give permission to Jacana Energy to set-up a payment arrangement for my account based on the information submitted in this form. I understand that my payment arrangement can be varied as required and I agree to notify Jacana Energy immediately if my circumstances change. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
