Empower

Please complete our Residential application
form below to join Empower:

My Preferences:

Yes, I would like Empower to become my new electricity retailer, and I have read Empower’s standard terms and conditions which apply. *

My Details:

Correspondence to : Title:

First Name: *

Surname: *

Premises: Unit No.:

Street No.: *

Street Name: *

Suburb: *

City: *

Postal Address:

Phone: (Home): *

(Work): *

Mobile Phone Number:

Email Address *

Account Holders name: *

Date of Birth:(dd/mm/yy) *

Other Authorised Person:

Next of Kin address:

Method of payment: *

* direct debit, automatic payment and credit card forms will be sent to you with your confirmation letter.

Are you the current electricity account holder? *

yes no

Are you the partner of the current account holder? *

yes no

Do you have authority to change electricity retailers? *

yes no

Have you had an electricity account with Empower before? *

yes no

Are you the homeowner? *

yes no

For this next section, you will need a copy of a recent electricity bill from your current supplier. All the information we need will be included on this account.

My current Supplier:
The details of my account are:

Current energy supplier:

ICP number.:

Average monthly spend:

If you are moving into new premises, please provide the date in
the box below:

The date I am moving in is:(dd/mm/yy)

You agree to purchase all electricity supplied to your premises according to our standard residential energy supply agreement. You also appoint us to:

Arrange the termination of all contracts with your existing electricity supplier(s).
Do all things necessary to arrange the commencement of supply to your premises as soon as possible, including authorising your existing supplier(s) to release to us any information held regarding the supply of energy to your premises.
Agree with your existing electricity supplier(s) estimated meter reading(s) for final billing purposes at the time of changing to us. However, we as well as you, have the right to terminate this agreement up to and including 10 days after the date that you submit this form.

All content Copyright© 2003, All Rights Reserved.
Empower Limited, PO Box 624, Wellington
Phone: 0800 34 00 00(Residential), 0800 307 000 (Business) - Fax: 0800 508 101
E-mail: support@empower.co.nz — Url: http://www.empower.co.nz
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