Applicant details
*
I am applying for this service for myself.
I am applying for this service on behalf of someone else.
Your full name:
First Name
Last Name
Which one of the following vulnerabilities do you require assistance for?
Visual impaired
Hearing impaired
Mobility issues
Long term medical condition
Water dependency
Elderly
In the event we need to access your property to provide you with bottled water, please let us know if you have any of the following:
Dog
A locked gate (if you have an electronic gate you can choose to provide us with the access code)
Other
Please provide us with the access code if you wish to do so:
Please provide us with additional information:
Which of the following statements apply?
I am blind.
I am partially sighted
I am elderly
Other
Which of the following statements apply?
Child under 12 months
Child under 5
Recovering from medical treatment
Other
Please indicate which of the following services you would like
*
Check meter reads for free.
Free Bottled water during a water outage.
Notifications of water outages.
Authorisation of alternative contact.
Nominate someone to self read meter monthly
Please indicate which of the following services you would like
*
Free Bottled water during a water outage.
Notifications of water outages.
Authorisation of alternative contact.
Check meter reads for free.
How long will the medical dependency last?
Permanent
Less than 12 months
Other
Please advise reason this address is considered water dependant
*
Number of people onsite
Please use the - or + to add the number of people
Any other useful information that we should be aware of?
Applicant's details
Full name of person registering for service:
*
First Name
Last Name
Property address
*
Email
*
example@example.com
Sign up for emailed invoices
Use the email address provided above
Use another email address for invoices
Daytime contact number
*
-
Area Code
Phone Number
Notification mobile number for water/wastewater alerts
-
Area Code
Phone Number
Authorised contact person
Please note
We understand the importance of water to our medically dependent customers and as such we have measures in place to ensure water is not turned off without advance notice and an alternative water supply arranged. However, despite those best efforts, occasionally water supply is interrupted because of extreme weather, accidents, technical problems or urgent maintenance. In case this happens, we recommend you have an emergency response plan in place. An emergency response plan could involve having bottles of water on hand, and going to a friend or family member’s house where water is available. If you need assistance preparing your emergency response plan, please contact us.
Please verify that you are human
*
Submit
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