New energy connection - Synergy

New energy connection - residential customers
Post completed forms to: Synergy New Connections, GPO Box K851, Perth WA 6842
Send online as an attachment at: synergy.net.au/residentialnewconnection or fax to (08) 6212 1045
Simply complete all fields, sign the form, then scan and attach your electronic application.
By completing this application you are entering into an agreement with Synergy to supply your electricity.
For a copy of the full terms and conditions, speak to your Synergy consultant or visit synergy.net.au
If you are applying for a multi-unit site, please visit synergy.net.au/multisite for an application form.
Fields marked with an asterisk (*) are mandatory. If not completed, your application will not be processed.
STEP 1: Account holder details
Account holder
1. *Title * Mr * Mrs * Miss * Ms * Other
*First name
Second name initial
*Surname
*Date of birth
*Phone
*Gender * Male * Female
Mobile
Email
*Your current postal address
Unit number *Street number *Street name/PO Box number
*Suburb/town
*Postcode
*Do you have an existing Synergy account?
* Yes * No
If yes, please provide the account number, name and address for this account
Account name and number
Account address
Suburb/town
Postcode
2. Alternate contact
Please note: This will be the secondary contact for the account.
The authorised contact person will become your agent on all Synergy accounts in your name. This means they will
have authority from you to discuss and perform any action on the accounts, including product changes, payments
and closure.
For further details on the matters an agent can act upon on your behalf, visit:
synergy.net.au/docs/authorised_representative_terms_conditions.pdf
If you have any existing contact person(s) on the Synergy account in your name, they will automatically have authority
on all your accounts. Please call Synergy on 13 13 53 to change these details.
*Title
* Mr * Mrs * Miss * Ms * Other
*First name
*Surname
*Date of birth
Second name initial
Phone number
*Gender * Male * Female
Please turn over
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STEP 2: New premises address
*I confirm that this address has been verified with my local council/Landgate and the titles have been released: * Yes * No
If titles have not been released, the account can not be established. Synergy is not able to change this premises address after
this application has been processed.
Unit number *Lot number Street number
*Street name
*Suburb/town
*Street type
*Postcode
*What is the purpose of the new premises?
* Solely residential * Solely commercial * Mix of residential and commercial
STEP 3: Type of supply
*Do you require a permanent supply?
* Yes * No
If your builder/electrician requires a temporary supply, please tick *
Please note: additional charges may apply. Visit synergy.net.au/prices for more information.
STEP 4: Third party consent – builder or electrical contractor
I authorise the below individual/company or their agent to exchange information, such as the account name and
premises address, for the purposes of establishing this new connection.
Builder/electrician name
STEP 5: Sign and date
By signing this application you agree to the details enclosed (under the supply agreement) and accept liability for any costs
incurred on this account.
*Applicant’s name
*Applicant’s signature *Date / /
* If you do not wish to receive marketing information from Synergy, please tick this box.
If you wish to update any details on your accounts at any time, please call us on 13 13 53
or go to My Account at synergy.net.au/myaccount
Collection of Information Notice
To assist us to provide you with services, we need to collect personal and credit information about you. We may disclose this information to other
parties (who may be located overseas), including third party providers, and to external agencies as described in our privacy policy, and may also
use your personal information for direct marketing purposes. Our privacy policy explains what information we collect and why we collect it, how we
use that information, who we work with, and the countries (currently the USA, Japan, Philippines and New Zealand) where those recipients may be
located. This policy also explains your rights to access and correct any information we store about you, how to make a privacy complaint and how
to opt out of receiving direct marketing. Our privacy policy is available at synergy.net.au/privacy_policy or by calling us on 13 13 53 for residential
customers or 13 13 54 for business customers.
We may also disclose your credit information to credit reporting bodies (CRBs) such as information about overdue payments. Our privacy policy also
includes important information about credit reporting such as the details about the CRBs to whom we may disclose your credit information, the
information that CRBs hold, and how you can request CRBs not to use or disclose your information for pre-screening or when you consider yourself
to be victim of fraud. You can request a copy of a statement setting out the important credit reporting information by contacting us.
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