Application form

1

Applicant Details
2

Site Location
3

Site Details
4

Connection Details
5

Declaration
6

Confirmation

Applicant Details

Company registration number

Parent company registered company name

Parent company registration number

If you are not a registered company/business, please provide the applicant’s name:

First name *

Last name *

If your address is outside the Republic of Ireland, please download a pdf version of this form and follow the instructions to email it directly.

Postal address *

Address Line 2 *

City *

County *

Eircode *

Primary phone *

Alternative phone

Email *

Are you an agent working on behalf of the applicant? *

Yes

Agent Details

First name

Last name

Company Reg Number

Company name

Postal address

Address Line 2

City

County

Eircode

Primary phone

Alternative phone

Please indicate whether it is the applicant or agent who should receive future correspondence in relation to the enquiry:

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