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: By ticking this box, I confirm that I have 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 online Peaksmart Reward Application Form at energex.com.au/positivepayback For more information or to view terms and conditions, visit energex.com.au/positivepayback PeakSmart air-conditioning Installation Form (upload with your online Reward Application Form) First Step Complete the below form with your installer 8564 08.09.2014