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Intermediary Sale of Energy Agreement

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Home > Tenants and Residents > Intermediary Sale of Energy Agreement

This agreement authorises WINenergy to manage the supply of your electricity.

Please fill in your required and relevant details on the form below.

If you'd prefer, you can download and print out a PDF copy of the form found on the right hand side of the page and fax it to us. Or, you can call WINenergy on 03 9822 4055 or 1300 791 970 to obtain a printed form.

Name of Tenant, Resident or Customer

Title/Prefix:


e.g. Mr, Ms, Mrs, Dr etc.

Given Name(s):

 * required

Surname:

 * required

DOB:

 * required
dd/mm/yyyy e.g 22/07/1970

Account Type:

Are you a
business      resident     * required

If residential customer must supply either details:

Drivers License:

 * as applicable

Passport Number:

 * as applicable

Document Issued In:

* as applicable

If business customer please supply all details:

Company Name:

 * as applicable

Business ABN/ACN:

 * as applicable

Life Support:

Do you require electricity for life support reasons?
Yes      No     * required

Electricity Supply Commencement Date:

 * required
dd/mm/yyyy e.g 22/07/2007
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Site Address

Street Address:

 * required

Address (cont.):

City/Suburb/Town:

 * required

State:

 * required
i.e. NSW, VIC, QLD, SA, WA, ACT, NT, TAS

Postcode:

 * required
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Your Contact Details

After Hours Phone:

 * required
e.g. 03 9822 4055 or 61 3 9822 4055

Business Hours Phone:

 * required

Mobile Phone:


e.g. 0418 894 448 or 61 418 894 448

Email:

 * required

 

 In the future we may wish to forward information about promotions or special offers that may interest you. If you wish to receive this information, please tick this box.
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Billing Details

 

Would you prefer to receive your account by email?
Yes      No     * required

 

 Billing Address same as Site Address

Billing Address:

 * required

Address (cont.):

City/Suburb/Town:

 * required

State:

 * required
i.e. NSW, VIC, QLD, SA, WA, ACT, NT, TAS

Postcode:

 * required
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Automatic Payment Details - this is compulsory for Residential Customers

 

 I/We authorize WINenergy Pty Ltd to arrange for funds to be debited from my/our account at the financial institution identified below and as prescribed through the Bulk Electronic Clearing System (BECS). This authorisation is to remain in force in accordance with the terms described below.

Institution:

 * as applicable
e.g. Westpac, ANZ, Commonweath Bank, etc

Account Name:

 * as applicable

Account BSB:

 * as applicable

Account Number:

 * as applicable
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Landlord/Leasing Agents Details (if applicable)

Title/Prefix:


e.g. Mr, Ms, Mrs, Dr etc.

Given Name(s):

Surname:

Company Name:


(if applicable)

Landlord Address:

Address (cont.):

City/Suburb/Town:

State:


i.e. NSW, VIC, QLD, SA, WA, ACT, NT, TAS

Postcode:

Business Phone:

Mobile Phone:

Email:

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Contract Exit Fee (if applicable)

If you have an existing contract with another energy retailer, WINenergy may pay out the exit fee for your contract. If you leave WINenergy before the end date of that contract, you will be required to repay WINenergy that exit fee. Please refer to the Terms & Conditions of this Agreement.

Contract End Date:


dd/mm/yyyy e.g. 22/07/2006 (if applicable)

Contract Exit Fee $:


e.g. 65 or 65.50 (if applicable)

Accept Agreement:

 * required
Please tick this box to confirm that you have read and agree to terms and conditions of this Agreement and the details you have given above are correct.


Terms and Condition of this Agreement
(opened in a new window)

 

Privacy Policy

WINenergy Pty Ltd — ABN 71 112 175 710

For assistance in completing this form, please call us on +61 3 9822 4055 or 1300 791 970 between 9am and 6pm Eastern Standard Time, Monday to Friday. Or you can contact us by an email to sales@winenergy.com.au.

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