CUSTOMER DATA COLLECTION FORM TO ESSENTIAL ENERGY APPLICATIONS

CUSTOMER DETAILS

Name

First Name

Last Name

Email

Phone

(###)

###

####

Mailing Address

If you are not the landloard, please provide Landloard details in the other information section.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

SITE DETAILS

Site Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

NMI NUMBER

You'll find your 11-digit NMI under 'Your electricity supply details' at the top of Page 1 of your electricity bill, in the 'Your details' section. If this is a new connection or you don't have an NMI, you must first contact the retailer of your choice to obtain a connection to an electricity network within New South Wales.

Electrical Work Details

Detail work to be carried out in

Point of Connection

Nearest Pole or Pit Number

Other information

Provide as much as information you can. Provide Landlord details here, if the customer is not the landloard.

Customer Consent:

This information is collected in line with Essential Energy Portal Requirements, and we are required to gather the above information and receive consent to proceed with the application.

By proceeding, the customer acknowledges and consents that Specialized Electrical Pty Ltd is authorized to disclose the information included in this connection application to Essential Energy for the purposes of Chapter 5A of the National Electricity Rules. Further, Specialized Electrical Pty Ltd is given permission to act on the property owner's behalf to make a submission of CCEW. The customer also understands that Essential Energy may contact them to confirm that they have provided their consent to Specialized Electrical Pty Ltd for completing and submitting this CCEW on their behalf.

By proceeding, you, the customer, are providing explicit informed consent to Specialized Electrical Pty Ltd to act as your agent with Essential Energy for the required processes. Please confirm your agreement.