Bin Request Form

Property type*

Notified by*

Owner/Propiertor*

Business Name

Property Address

Street Address:*

City:*

State:*

Post Code:*

Country:*

Phone Number*

Email (must be contactable in relation to Bin Request)*

Assessment number (if known)

Service Required*

Please list quantity if additional or replacement bin request or any specific information related to a collection alteration

I declare that I am the ratepayer/property manager of this property and the above information is true and correct. Please note that we may not action requests that do not have a means of contacting someone in Exmouth by phone or email.*

YesNo

Signature date*

Signature*

Welcome to the Shire of Exmouth

General Office:

Address