Customer Action Request

Customer Action Request
Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
E-mail
Object *

Footpath Road Tree
Road name *
Between roads (if applicable)
Town Request is being reported in *

Nhill Dimboola Rainbow Jeparit
Detected Location
Option to add photo of defect

Browse Files

Cancel of
Request details *
Reason for request
Upon receipt of your request, an inspection of the defect will be carried out within 7 days. If you would like to be contacted with the outcome of the inspection, please select your preferred correspondence option below.
Would you like to receive a follow up response from Council: *

Yes No
If yes, please select your preferred contact method:

Phone Email Letter
Should be Empty: