Safe Disconnect Request Form

Service Required
Which disconnection service would you like?*

Business hours (8am - 4pm Mon-Fri excl. public holidays)After hours (after 4pm Mon-Fri weekends and public holidays)
Which re-connection service would you like?*

Business hours (8am - 4pm Mon-Fri excl. public holidays)After hours (after 4pm Mon-Fri weekends and public holidays)Not required
What address(es) do you need disconnected?*

Street Address

Street Address Line 2

CityRegion

Postal / Zip Code
What is your relationship to this property?*

LandownerTenantTradesperson or contractorOther
Is the line*

High voltageLow voltageDon't know
What kind of work are you planning?*

Electrical workBuilding or building repairsPainting water blastingTree trimmingOther
Will this disconnection affect others?*

YesNoDon't know
Which, if any other services do you need?

Power line work (eg repair drop remove tighten).SafeTrim tree (eg trim or remove).Electrical inspectionOther
Feel free to make any other comments about your needs here:
Disconnection

The planned date is your preferred date for the disconnection.

An alternative date is required should your preferred not be available.
Planned date for disconnection*

DayMonthYear
Date
Alternative date for disconnection*

DayMonthYear
Date
Start time*

Hour Minutes

AM/PM Option
End time*

Hour Minutes

AM/PM Option
Reconnection
Reconnection required?*

YesNo
If a reconnection is required, please provide a planned reconnection date (this is your preferred date) and an alternative reconnection date, should you preferred date not be available. This may be on the same day as your disconnection.
Planned date for reconnection

DayMonthYear
Date
Alternative date for reconnection

DayMonthYear
Date
Requester Details

Please enter your contact details:
Name*

First NameLast Name
Daytime contact phone number*

Area CodePhone Number
Email*
example@example.com
If you prefer us to contact a tradesperson or someone else about these arrangements, please enter their details here:
Name

First NameLast Name
Daytime contact phone number

Area CodePhone Number
Email
example@example.com
Should be Empty:

Service Required

Disconnection

Reconnection

Requester Details