Customer Request Management Entry

Instructions

You are a member of the public, please fill this form in.

Rates Direct Debit request

Enter Details of Request *

Enter a description of events/problem.

Customer Details *

Customer

Name

Title

Surname / Company

Given

Contact Details

Residential address

Street address

Street address 2

Street address 3

Street address 4

Street address 5

Postcode

Postal address if different from residential

Street address

Street address 2

Street address 3

Street address 4

Street address 5

Postcode

Work

Home Phone

Mobile

Fax

Contact By

Not required

Telephone

I would like to: (Required)

Assessment number

Property Address Details

Search for the property the call is in relation to.

Building

Unit

Level Number

House

Street Name (without type)

Suburb

Title Type

Title 1

Title 2

Title 3

Title 4

Title 5

Title 6

Advanced search

Street Location Details

Select a Suburb and Street the call is in relation to.

Select Street

Select Suburb

Additional Location Description

Enter a description of the location related to the call.

Description

Attachment

Upload an attachment from your computer to link to this call.

/eservice