Customer Consent Form – Appointment of Electricity Marketing

Customer Consent Form – Appointment of
Electricity Marketing Agent (Agent)
In this form:
the Customer means the person(s) named as such below, having one or more electricity supply accounts with Synergy. If a Customer
has multiple electricity supply accounts with Synergy, the Customer must nominate on this form each electricity supply account and the
associated premises to which the authority and consent in this form relate to;
•the Agent means the person the Customer is, by completing this form, authorising to act on the Customer’s behalf in relation to the supply of
electricity to the Customer;
•a reference to a person includes, but is not limited to, an individual, a public body, a company, or an association or body of persons, corporate
or unincorporated;
• premises means each address to which electricity is or will be supplied to the Customer under the relevant electricity supply agreement; and
• Synergy means Electricity Generation and Retail Corporation trading as Synergy ABN 58 673 830 106.
Customer details, authorisation of Agent and consents etc.
Customer name _______________________________________________________________________________________________________
Customer address������������������������������������������������������������������������������������
ABN/ACN (if applicable)��������������������������������������������������������������������������������
I/We now appoint and authorise the Agent* named on this form to act on my/our behalf in relation to the supply
of electricity to me/us on the account(s) and at the premises listed below, for the period of:
________________________ (start date) to_____________________(end date).
*Neither this appointment nor this authorisation can be cancelled, revoked, varied or terminated in whole or any part before the above end date
without Synergy’s written consent (not to be unreasonably withheld).
Account name
Physical address of premises
Account number
I/We also consent to Synergy releasing all and any information requested by my/our Agent from time to time in
relation to the supply of electricity at the premises to my/our Agent.
I/We acknowledge and agree that my/our Agent may enter into legally binding arrangements with Synergy on
my/our behalf in relation to the supply of electricity to me/us at the premises including but not limited to contract
establishment, liability for payment and contract termination and that my/our Agent does not act for Synergy and
is not authorised, at any time, by Synergy to act for, or on behalf of, Synergy.
For further details on the matters an agent can act on your behalf, visit:
I /We do not consent to Synergy contacting me/us regarding any promotional or marketing activities
(please tick box if appropriate)
Date ___________________________________________________________________
*If person signing is not the Customer, the person signing must be duly authorised by the Customer to sign this form and must produce evidence
of that authority to Synergy upon request.
Name of each person signing this form for the Customer ���������������������������������������������������
Daytime contact no__________________________________ Mobile_______________________________
MKSYN0002B_G June 2014
Email address ____________________________________________
Agent details and acknowledgement
Agent name �����������������������������������������������������������������������������������������
Agent address ���������������������������������������������������������������������������������������
ABN/ACN (if applicable)��������������������������������������������������������������������������������
I/We understand, acknowledge and agree that by signing this form:
•I/We accept the above appointment and authorisation by the Customer in accordance with its terms;
•I/We may become an Electricity Marketing Agent for the purposes of the Code of Conduct for the Supply
of Electricity to Small Use Customers†, as in force from time to time;
•I/We must comply with that Code and it is my/our responsibility to make myself/ourselves aware of the
requirements of that Code and the consequences for me/us if I/we do not comply; and
•If there is more than one of us as Agent then we are jointly and individually able to exercise any right of the
Agent and jointly and individually liable for any obligation of the Agent and any notice, consent, licence,
permission, authority, receipt or other communication given by any one of us to Synergy, or received by any
one of us from Synergy, is deemed to be given or received (as the case may be) by all of us.
Available from
Executed by the Agent:
Agent’s signature* ������������������������������������������������������������������������������������
Witness’ signature ������������������������������������������������������������������������������������
Date ___________________________________________________________________
*If person signing is not the Agent, the person signing must be duly authorised by the Agent to sign this form and must produce evidence of that
authority to Synergy upon request.
Name of each person signing this form for the Agent
Daytime contact no.__________________________________ Mobile___________________________________
Email address ____________________________________________
Please return this form to:
Synergy GPO Box K856, Perth WA 6842
or fax (08) 6212 1035
Collection of Information Notice
To assist us to provide you with services, we need to collect personal and credit information about you. We may disclose this information to other
parties (who may be located overseas), including third party providers, and to external agencies as described in our privacy policy, and may also
use your personal information for direct marketing purposes. Our privacy policy explains what information we collect and why we collect it, how we
use that information, who we work with, and the countries (currently the USA, Japan, Philippines and New Zealand) where those recipients may be
located. This policy also explains your rights to access and correct any information we store about you, how to make a privacy complaint and how
to opt out of receiving direct marketing. Our privacy policy is available at or by calling us on 13 13 53 for residential
customers or 13 13 54 for business customers.
MKSYN0002B_G June 2014
We may also disclose your credit information to credit reporting bodies (CRBs) such as information about overdue payments.
Our privacy policy also includes important information about credit reporting such as the details about the CRBs to whom we may disclose your credit
information, the information that CRBs hold, and how you can request CRBs not to use or disclose your information for pre-screening or when you
consider yourself to be victim of fraud. You can request a copy of a statement setting out the important credit reporting information by contacting us.