1345 30.04.2021

Electrical Part of Energy Queensland

Request for Removal / Disconnection of Energex Electrical Assets for Unmetered Supply, Rate 8 & Rate 3 Lighting & Watchman Lighting

On completion, please fax this request to the current Electricity Retailer

Applicant Details

You must forward this form to the current electricity retailer to request Energex to perform this work.

Name (please print)

Name of Property Owner (if not applicant)

Company Name

Position

Applicant’s Postal Address

Preferred Contact

Telephone Numbers

Email Address

Work

Postcode

Facsimile Number

Mobile

Request / Notification Details

Address / Property Name (i.e. opposite No. 10 Smith Street, Newstead)

Site to be Disconnected (i.e. Bus Shelter)

NMI No. (if known)

Load Details (if known)

Service to be Removed (indicate type of supply)

Date Supply Abolishment required

Pole No.

Street Light No

Pillar No

Pit No

I agree not to conduct any removal / demolition works at the aforementioned property until confirmation has been received from Energex advising that requested Energex electrical assets have been removed.

Signature Date

Energex Use Only

Confirmation of Utility Disconnection Yes No

Retailer Retailer Service Order Number

Position

Signature Date

Energex Limited GPO Box 1461 Brisbane Queensland 4001 ABN 40 078 849 055

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