Energy voucher application form

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* Required fields

Customer details

Given name *

Surname *

Date of birth * dd/mmm/yyyy
(Example 20/Apr/1994)

Contact details

Daytime phone number *

(Example: 0x xxxx xxxx or 04xx xxx xxx)

Email address

Supply address

Street address *

Suburb *

Postcode *

State *

Concession card details (if applicable)

By supplying us with your concession card details we can help ensure all eligible energy rebates are applied to your accounts.

Do you wish to add concession card details? * YesNo

Energy Saving Advice

Has energy savings advice been provided to you? YesNo

Account details

Select which account to apply voucher.

Account type * ElectricityNatural gas

Account number *

Voucher code

Please enter the voucher code provided by ActewAGL. Only one code can be applied to each voucher.

Each voucher is valued at $100 and is limited to one per person. The voucher amount will be applied to either the electricity or gas account nominated by the customer in this form.

Voucher code *

Authorisation

* I authorise ActewAGL to make any enquiries necessary to confirm eligibility for the rebate.

You must give your authorisation for the application to be submitted.

(Information provided by Centrelink and /or Veterans' Affairs is limited to a confirmation of you being a pensioner with fringe benefit eligibility and other details which need to be confirmed. The departments will under no circumstances release any other information to ActewAGL).

Your privacy is important to us and we are committed to handling your personal information in accordance with the Privacy Act 1988 (Cth). Our Privacy Policy sets out how we collect, hold, use and disclose your personal information. Read ActewAGL's privacy policy in full here.