Single Meter Fix Request Form - Victoria

Phone No: / 132 973 / Fax No: / 1300 131 002 / Email: /

Important: To ensure prompt installation of a gas meter it is important that the following are in place prior to submitting this request:

·  Gas service line is installed / ·  Property clearly marked with street and lot number / ·  Clear access to gas meter location
·  Bollards requirements checked where gas meter is on drive side of property / ·  Distance of electrical connections and appliances from gas meter meet regulatory requirements / ·  Fitting lines marked with unit numbers on unit developments
Failure to comply with any of the above generally result in cancellation of requests by the gas network and subsequent delays in the gas meter being connected.

Account Holder Information: Named party consents to having Origin as their gas Retailer

Full first and surname (initials not accepted) and telephone number must be supplied.

First Name: / Surname:
Telephone: / Date of Birth:

(2nd person details – optional)

First Name: / Surname:
Telephone: / Date of Birth:
Postal Address:

Display/ Spec Home or Business including Trust Funds:

Complete this section if the account is to be established in a business or Trust name

Company Name: / ABN:
Business Address: / Postal Address:

Business Contact Details (must be provided)

First Name: / Surname:
Telephone: / Position:

Connection Address Information:

Lot No.: / Unit No.: / Street No.:
Street Name:
Town/Suburb: / Postcode:

Gasfitter Information: Please note license, certificate numbers and load details must be provided

License No.: / COC/ESV/SWN:
Megajoule Total: / 1.10kpa / 2.75kpa
Plumber Name: / Plumber Phone No.:

Special Instructions: Please advise if there have been any address changes since gas service line was requested or if a special quotation was required for your service line and gas meter connection. Business connections please advise number of hours a day and days a week business will operate.

Privacy: To find out more about how Origin collects, uses, holds and discloses your personal and credit information see our privacy and credit reporting statements at originenergy.com.au/privacy. Our credit reporting statement explains who we disclose credit information to (including service providers overseas) and how this could affect your creditworthiness, as well as how you can access, correct or complain about it. Please contact us to request a paper copy. If you provide us with personal information about another person, please make sure you tell them their information has been provided to us and tell them about our privacy statements.

Please submit request a minimum of 5 business days prior to date gas meter is required.

Follow up enquiries regarding your request may be emailed to .

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