Scheme participant application

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To become a member of Energy and Water Ombudsman Queensland, you need to submit an application.

Privacy statement

We collect confidential information on this form as required by the Energy and Water Ombudsman Act 2006 (the Act).

Under the Act, we may provide some information to the public, such as publishing your organisation’s name and website link on our website.

We won’t disclose your personal information to any third party without your consent or unless authorised or required by law under the Information Privacy Act 2009.

Part 1 - Details

Organisation details

Organisation name *

ABN *

Phone *

Email *

Website

Address

Street address *

Suburb *

State *

Postcode *

Postal address

Same as address

Same as address

Postal address

Suburb

State

Postcode

Retail authority

AER Retail Authority *

Product

Electricity
Gas

Scheme participant date of effect * The date you’ll start providing services to customers in our jurisdiction.

Day Month Year

Part 2 - Contacts Please provide direct phone numbers and email addresses. You must tell us if any of these details change.

Scheme participant contact The person who will update changes to the information below.

Salutation *

First name *

Surname *

Position *

Phone *

Email *

Media contact The person we can contact directly during business hours about media related enquiries and community outreach opportunities.

Same as above

Same as above

Salutation

First name *

Surname *

Position *

Phone *

Email *

Finance contacts The people we can send invoices to for payment (e.g. membership invoices, quarterly advance invoices, half-yearly adjustment invoices and unpaid fee invoices), as well as half-yearly complaint information and budget guidelines.

Primary finance contact

Same as above

Same as above

Salutation

First name *

Surname *

Position *

Phone *

Email *

Secondary finance contact

Salutation

First name

Surname

Position

Phone

Complaint contacts A generic email address for investigation notifications, and contact details of the team leader of your customer service unit, their direct manager and the general manager they report to.
We must be able to contact them directly during business hours if we’re investigating a complaint against your organisation.

Generic email address *

Team leader

Same as above

Same as above

Salutation

First name *

Surname *

Position *

Phone *

Email *

Direct manager

Same as above

Same as above

Salutation

First name *

Surname *

Position *

Phone *

Email *

General manager

Same as above

Same as above

Salutation

First name *

Surname *

Position *

Phone *

Email *

CEO (or equivalent) contact

Same as above

Same as above

Salutation

First name *

Surname *

Position *

Phone *

Email *

Part 3 - Declaration

Declaration *

I confirm the information provided in this form is true and correct in every detail.

Date *

Day Month Year

Your organisation

Organisation name *

ABN

Email *

Phone *

Website

Exemption class

Number of residential customers

AER reference (if registered)

Address

Street address *

Suburb *

State *

Postcode *

Postal address

Same as address

Same as address

Postal address

Suburb

State

Postcode

Your details

Salutation *

First name *

Surname *

Position *

Phone *

Email *

Complaint contact

Same as above

Same as above

Salutation

First name *

Surname *

Position *

Phone *

Email *

Finance contact

Same as above

Same as above

Salutation

First name *

Surname *

Position *

Phone *

Email *

Declaration

Declaration *

I confirm the information provided in this form is true and correct in every detail.

Date *

Day Month Year