Safe Disconnect LV Non Standard

Name*

First NameLast Name

Phone Number*

Phone Number

Email*

example@example.com

If you prefer us to contact a tradesperson or someone else about these arrangements, please enter their details here:

Tradespersons Name

First NameLast Name

Phone Number

Which disconnection service would you like?*

Business hours (8am - 4pm Mon-Fri excl. public holidays, no cost incurred)After hours (after 4pm Mon-Fri weekends and public holidays, an extra charge will be due for after hours)

What address(es) do you need disconnected?*

Street Address

Street Address Line 2

CitySuburb

Postal / Zip Code

What kind of work are you planning?*

Electrical workBuilding MaintenanceNew Building/Structure (All structures must meet the requirements of ECP34. Depending on the proximity of the new structure to the lines, further consultation may be necessary please call 0800 100 202) https://www.countiesenergy.co.nz/forms/new-connection-for-residentialTree Trimming (If application is approved, please Call control room before and after work)Other

Feel free to make any other comments about your needs here:

Preferred date for disconnection (at least 20 business days notice required)*

Date

Start time*

Hour Minutes

AM/PM Option

End time*

Hour Minutes

AM/PM Option

Disconnection Zone

Pole number - start of work area

Pole number - end of work area

Photos of both pole numbers required