Fields marked with * must be entered

SECTION A - Your Personal Details
Full Name:*
Home Telephone:*
Mobile:
Work Telephone:*
Address:*
Suburb:
City:*
E-Mail:*
ICP Number (located on your gas invoice):*
Current Meter Reading:
Meter Reading Date (DD/MM/YYYY):	/ /
How did you hear about E-Gas?:	Please Select Current Customer Flyer Friends / Family Internet Yellow Pages Other
SECTION B - Current Invoice Details
Current Daily Rate (Excl. GST):* e.g. 1.24 = $1.24 per day Current Variable Rate (Excl. GST):* e.g. 0.0624 = 6.24 cents per kWh Current Prompt Payment Discount: Please Select1%2%3%4%5%6%7%8%9%10%11%12%13%14%15%16%17%18%19%20% Current Supplier*: Please Select Auckland Gas Company Bay of Plenty Electricity Contact Energy Directenz FreshStart Energy (Now Genesis) Genesis Energy Greymouth Mercury Gas NGC Nova Gas On Energy (Now Genesis) Wanganui Gas Other
SECTION C - Your preferred payment method?
Payment Option Direct Debit Direct Credit Cheque Sales Represenative Please SelectAidan CreamerBrendan CreamerCarole MarsdenCliff HuntColin TaylorDavid LeeDavid McNeillDean LongfordGwen KongLisa LeeLorraine ThompsonRodney MooreSharyn Rudolph
SECTION D - Preferred E-Gas Gas Supply contract Term?
Contract Term 1 Year 2 Year