Application QGA

Customer Name*
If company - put company name here
Company ABN
Contact Name*
Authorised Person Making this Application*
Phone*
Email*
Installation Address*
Installation Suburb*
Installation Address Postcode*
Location Address*
Location Suburb*
Location Postcode*
Billing Address*
Billing Suburb*
Billing Postcode*
Billing State*
Referring Gas Fitter Details
Name of Company
Contact Person
Phone
Appliance Type*
Appliance Age*
Description of Appliance*
Manufacturer*
if unknown, please type unknown
Make*
if unknown, please type unknown
Model*
if unknown, please type unknown
Serial Number*
if unknown, please type unknown
Mobile Vehicle details (only fill out if relevant)
Mobile Vehicle Type
Make
Model
Is the Vehicle Second AND imported?
Yes
No
VIN
Year
Gas Consumption*
if unknown, please type unknown
Injector Size/s*
if unknown, please type unknown
Gas Types
Installation Instructions Supplied?*
Yes
No
if yes - please upload below
Has the Appliance Been Installed?*
Yes
No
Specifications Supplied?*
Yes
No
if yes - please upload below
Country of Origin*
if unknown, please type unknown
Copy of Manual Supplied with Application?*
Yes
No
if yes - please upload below
Nameplate on Unit?*
Yes
No
Supporting Documentation

File must be one of the following types pdf,doc,docx,jpeg,jpg and
Be less then 4.88 Mb

Please upload any support documentation
Is the equipment a Domestic or Commercial Type A Gas Appliance?*
Yes
No
The appliance has the correct jets for the gas type it is operating*
Yes
No
There is gas available to test the appliance*
Yes
No
The appliance will not be used in the absence of a Gas Safety Approval*
Yes
No
A gas fitter has been contacted to assist in connecting the appliance*
Yes
No
The appliance has a name badge on the equipment listing Model number, serial number, manufacturer, gas type, injector sizes, gas pressure and mega joule rating*
Yes
No
If the unit has electrics, a full diagram and name plate has been supplied*
Yes
No
N/A
The technical and operational manual for the unit has been supplied*
Yes
No
The unit is gas tight and safe to operate*
Yes
No
The unit will be in an operating situation to assist the process*
Yes
No
A digital photo of the unit has been supplied *
Yes
No
Terms*

I Agree to the below conditions:
  • I hereby certify that the above appliance meets the safety requirements for gas devices (Type A)
    As detailed under s733 of the Petroleum and Gas (Production and Safety ) Act 2004
    All Type A gas devices must be approved before they may be supplied, installed or used.
  • The information provided in this application is true and accurate.
  • I understand there is a $112.00 non-refundable application fee
Please enter the below letters into the field below
New Image
Next Step