Intellihub Relevant Agent Appointment Form

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Customer Details

Surname

First Name

Business Name

ABN

Telephone

Mobile

Supply Address Details

NMI

Lot no

Unit no

Street no

Street Name

Suburb

Post Code

State

Postal Address Details

Lot no

Unit no

Street no

Street Name / PO Box

Suburb

Post Code

State

Installation Details

Name

Contact Phone

Inverter type:

Solar

Battery

Inverter phases:

Single Phase

3-Phase

Intended disconnect mechanism:

Direct

Contractor

DRM

Inverter nameplate rating (kW)

Name of Retailer

I opt out of electronic communications related to remotely disconnection and reconnection notifications. I also acknowledge that general notifications will continue to be sent via email and other electronic means.

Signature

Sign Date

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