We are collecting your personal information in accordance with the Information Privacy Act 2009 for the purpose of processing this application/request. The information will be only accessed by authorised employees. Your information will not be given to any other person or agency unless you have given us permission, or we are required by law.

Application type*

New

Renewal

Have any details changed?*

E.g. moved house, etc.

Yes

Applicant

Applicant name*

First Last

Applicant phone number*

Applicant email address*

Are you applying on behalf of someone else?*

Yes

Property details

Name of resident who requires service

First Last

Phone number of resident who requires service*

Email of resident who requires service

Residential address*

Street Address Address Line 2 Town Post code

Postal address same as property address?*

Yes

Postal address*

Street name or PO Box Address Line 2 Town State Post code

Property number

From your rate notice

Lot and plan number

e.g. Lot 4 on RP732163

What is your preferred method/s if we need to contact you to arrange a property inspection?*

Phone

Letter

Upload supporting documentation from a medical professional.*

E.g. GP, occupational therapist, health care professional or nursing agent.

Max. file size: 100 MB.

We acknowledge the Traditional Custodians of the Tablelands Region and pay respect to Elders past, present and emerging.

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