ActewAGL Support Form

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* Required fields

Customer details

Given name *

Surname *

Date of birth * dd/mmm/yyyy
(Example 25/Apr/1994)

Contact details

Daytime phone number

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

Email address

Are you experiencing family violence or financial abuse? YesNo

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

Account details

Electricity account number

Natural gas account number

Water & Sewerage account number

What can you afford to pay regularly towards your account(s)?

Electricity

Gas

Water & Sewerage

Start date for Payments to commence

Day of the week

First payment date dd/mmm/yyyy
(Example 25/May/2024)

Payment Method

Do you have any other medical requirements you need to advise us of? YesNo

Is there anything else you'd like us to know? YesNo

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.