South Island Commercial LPG Application Form

Please complete the details below. alternatively print a copy of the application form and mail or fax it to us, if you have any questions about filling in this form please contact our customer care team on 0800 668 257.

Printable application form (PDF file)

Once your application is approved we will contact you confirm your details and arrange your initial delivery. You should receive your first account from Nova Energy within six weeks and we will contact you if we require any further information from you. Your energy will be supplied under Nova Energy’s Standard Terms of Commercial LPG Supply and fees may apply.

Are you currently or have you ever been a Nova Energy customer?:

Yes

Company Name: *

Trading Name:

If different from above

Authorising contact person: *

Position held: *

Street number: *

PROPERTY ADDRESS

Flat number:

Street name: *

Suburb:

City/Town: *

Street number:

POSTAL ADDRESS (if different from above)

PO Box/Private Bag:

Street name:

Suburb:

City/Town:

Work Phone:

Home Phone: *

Mobile:

Email address: *

Date for supply to commence:

If you are currently occupying the property enter today's date

Number of cylinders required 45KG:

Number of cylinders required 90KG:

Number of cylinders required Forklift:

Any specific requirements:

Company Name: *

PLEASE SUPPLY 3 CREDIT REFEREES

Address: *

Phone: *

Company Name: *

Address: *

Phone: *

Company Name: *

Address: *

Phone: *

I have read and agree to the terms and conditions

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