SECTION A: Applicant Details

This application being made by an individual a business a builder

First Name: Last Name:

Business Name (if applicable): ABN:

Address (where the device is installed)

Unit No. Street No. Street:

Suburb: State: Postcode:

SECTION B: Installer Details (to be completed by the Installer)

Company Name: Installer Name:

Licence No. Phone No. Installation Date:

Electrician Refrigeration Mechanic Email Address:

Bytickingthisbox,IconfirmthatIhave successfully installed a Signal Receiver(s) into a ‘PeakSmart’ Compatible Air-conditioner(s) as outlined in SECTION C below in order that the Applicant can apply to participate in the ‘PeakSmart’ Compatible Air-conditioner Program.

SECTION C: ‘PeakSmart’ Air-conditioner and Signal Receiver Information (to be completed by the Installer)

Air-Conditioner (1) and Signal Receiver (1)

A/C Brand: A/C Model No.

Signal Receiver DCR No. DCR A/C Location:

Air-Conditioner (2) and Signal Receiver (2)

A/C Brand: A/C Model No.

Signal Receiver DCR No. DCR A/C Location:

Air-Conditioner (3) and Signal Receiver (3)

A/C Brand: A/C Model No.

Signal Receiver DCR No. DCR A/C Location:

Air-Conditioner (4) and Signal Receiver (4)

A/C Brand: A/C Model No.

Signal Receiver DCR No. DCR A/C Location:

Air-Conditioner (5) and Signal Receiver (5)

A/C Brand: A/C Model No.

Signal Receiver DCR No. DCR A/C Location:

Next Step After you complete this form, please save it onto your computer and attach it to your onlinePeaksmartRewardApplicationFormatenergex.com.au/positivepayback Formoreinformationortoviewtermsandconditions,visitenergex.com.au/positivepayback

PeakSmart air-conditioningInstallation Form(uploadwithyouronlineRewardApplicationForm)

First Step Completethebelowformwithyourinstaller

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