Customer Request Form

Required fields are marked with an asterisk (*).

The Customer Request Form allows you to log a query to Council at any time. To log a request with Council please complete all of the fields and then click the submit button. Your request will be immediately sent through to the relevant Council staff member.

Contact Details

Firstname *

Surname

Mobile Enter your mobile number without spaces

Home phone Enter your phone number without spaces

Work phone Enter your phone number without spaces

Address line 1

Address line 2

Postcode Enter your postcode without spaces

Suburb

Customer Request Form

Date of Request *

Day Month Year

Brief Details of Request *

Location *

Do you wish to be contacted about your request? *

Preferred method of contact *

Email
Phone Call
SMS
Not Applicable

Customer Request Form

Contact

Bordertown Office

Keith Office