Connection Request Form

Job Address

If additional appliances will be provisioned, please list below. The gas retailer must populate this section If Gas Booster is required, please provide manufacturer details (i.e. data sheet or specification sheet)

EXISTING

PROPOSED

NEXT 3 YEARS

(Please read carefully)
By completing this form, you acknowledge that:

• The information you have provided is true and accurate. Your claim may be refused if information is deemed untrue or incorrect
• Delays may occur in processing your claim if insufficient evidence has been submitted
• You are authorised to submit the application of the gas service request
• Personal information collected on this form will be used to process and administer your connection request
• Your personal information may be shared with our contracted service providers or third parties (service laying contractor) for the purpose of assessment and installation of services, and you consent to this disclosure
• The gas connection process may also involve the collection of additional personal information regarding the connection from a third party (ie Vic Roads, Councils, etc) and you consent to this collection and disclosure
• Your personal information may be contained in reports commissioned by Multinet Gas to process your claim. These reports are the sole property of Multinet Gas Note: Full details on how your personal information (including sensitive) may be used, handled or disclosed by us and how you may request access to your personal information is contained in our Privacy Policy at https://www.multinetgas.com.au/privacy
• You have read and submitted all relevant load information, site contact details and site plans with your application
• Multinet Gas reserves its right at law.