Account Form Submission | Southern Gas Services Limited

ACCOUNT APPLICATION FORMS

Save time and fill out your online applicaiton and direct debit forms

PRIVATE USER ACCOUNT FORM*

Date of Application*

Date Processed by SGSL*

Office Use Only

Processed by*

Office Use Only

CUSTOMER DETAILS*

Full Name*

First

Middle

Last

Preferred Name*

Delivery Address*

Billing Address (If different from above)*

Contact Phone Number*

Additional Phone Number*

Email Address*

Would you like your invoices and statements to be emailed to you on the above email address?*

Next of Kin (Please provide next of Kin contact details)*

First

Middle

Last

Contact Phone Number*

Additional Phone Number*

Type of Photographic ID*

SGSL requires 1 form of Photographic ID to complete you application

Sighted*

Office Use Only

Direct Debit Forms Completed*

Confirmation of Terms and Conditions*

I certify that the above information is true and correct and that I have the authority to make this purchase and pay any outstanding amounts in a timely fashion in accordance with Southern Gas Services Limited’s (“SGSL”) payment terms and conditions of sale (Including and on-going rentals for SGSL’s leased equipment according to SGSL’s records) I agree to be bound by the terms and conditions of trade (See overleaf) of SGSL. Full terms and conditions may be downloaded on our website – www.southerngas.co.nz/Terms&Conditions which form part of and are intended to be read in conjunction with this application and the Gas Supply Agreement between the parties, The Gas Supply Agreement will prevail if there is a conflict with the terms and conditions. I understand that if I default or cancel any direct debit payments, I authorise SGSL to debit my credit card (as provided) for any monies owned.

Do you accept the terms and conditions?*

YES I AGREE

Customers Full Name*

Customers Signature*

Date*

*Form Fields Are Required!

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