Concession Form

(*) Denotes required fields

Section A: Your details (Please fill in details as per your Concession Card)
Click Energy Account Number
First Name *
Surname *
Address *

Email *
Phone *
Mobile
Is the above address your principal place of residence? * YES NO
Section B: Type of concession or rebate:
Issuer *
Card Number *
Card Type *
Card Start Date *
Card Expiry Date *

	I authorise Centrelink to confirm with Click Energy the current status of my Commonwealth Benefit and other details as they pertain to my concessional entitlement. This involves electronically matching details I have provided to the Participant with Centrelink, Department of Veterans' Affairs (DVA) or Department of Communities (DOC) records to confirm whether or not I am currently receiving a Centrelink, DVA or DOC benefit.
	I understand that if I withdraw my consent, I may not be eligible for the concession provided by Click Energy.
	A brochure is available from Centrelink that provides more details about Centrelink Confirmation Services or on Centrelink's website at http://www.centrelink.gov.au.
	I confirm the following; that I live alone or I share the premise with my spouse or wholly dependent person or another person who also holds a Government Seniors Card or Pensioner Concession Card or persons who receive an income support payment from Centrelink, Family Assistance Office or Department of Veterans' Affairs who do not pay rent; or other persons who live with me to provide care and assistance, and who do not pay rent.
	I confirm that no other person(s) excepting casual visitors share the residence.
	I understand that this consent, once submitted, is effective only for the period I am a customer of Click Energy. I also understand that this consent, which is ongoing, can be revoked any time by giving notice to Click Energy.