Coastwatch Life Support Electricity Form

Life Support Registration Form

To complete this connection form you will require the following:
5 Minutes of Your TimeCompleted Life Support FormIdentification (Drivers License/Passport or Equivalent)Mobile Phone NumberEmail Address

Do you or anyone living with you at your premises require life support equipment?*

Important Reminder
The form will only be completed and submitted when you see the following screen.
Make sure you click on the next button on each page until you see

located under the "feedback" page.

Oooops!

You have come to the Life Support Form.

Please go to

www.coastwatchumr.com

or

Please call 1300 843 756 for further options.

Sorry for any inconvenience caused.

Valued Customer Details
Meter Number*
This is a 11 Digit Number Located on your meter and or swithboard
Customer Type*
Full Legal Name*

PrefixFirst NameMiddle NameLast Name
Trading Name*
ABN/ACN*
Connection Billing Address*

Unit Number

Street Address

CityState / Province

Postal CodeCountry
Mobile Number*
E-mail*

Identification Documents
Personal Identification Type*
Authentication Number*
Date Of Birth Day/Month/Year*
Upload a File
Please Take Photo Of Your ID (If screen is black press the turn camera around button top right corner) Cancelof

Concession Eligibility
Do you hold any of the following cards?

Pensioner Concession Card Issued by the DHS/DVADHS Health Care CardDVA Gold Card
Authentication Number*
Concession Card Upload*

Upload a File
Please Take Photo Of Your ID (If screen is black press the turn camera around button top right corner) Cancelof

Account Connection Payment
At Coastwatch we like to make things simple. Please review our rates page at www.coastwatchumr.com/rates.

Please review our rates page at www.coastwatchumr.com/rates

Account Set Up Move In Reading Fee$55.70AUD

Subtotal $0.00AUDTax $0.00AUDTotal $0.00AUD

Payment Method
Credit	Express

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Connection Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Terms & Conditions
I Agree With The Above Terms & Condition

Feedback
How was your sign up experience?
Comments
We welcome your feedback. Please tell us where we can improve the customer experience.

If the form is complete and accepted you will be redirected to a page where you can purchase your first electricity token.

Please allow up to 3 hours to be able to purchase electricity for your account.
Should be Empty: