\\DBK-FS1\data\Engineering\Engineering Administration\Forms\Form WS030 Works & Services Request Form.doc

WORKS & SERVICES REQUEST FORM

Date: Time: Taken By:

WR #: Assessment #:

CUSTOMER DETAILS:

Name:

Address:

Locality: P/C:

Phone (Home): (Work):

Mobile:

Email:

Please tick box of preferred option of contact

NATURE OF REQUEST:

TREES / BRANCH ROAD MAINTENANCE PARKS & GARDENS

Fallen On Road (please

complete information below *)

Grading Mowing

Pot Holes Toilets

Fallen Other (please complete

information below *) Drains, Culverts Playground Equipment

Dangerous Verges Reticulation

Blocking view Bridges Bins

Other Other Other

If other, please describe:

LOCATION & NATURE OF WORKS:

Road, Park, Reserve, Building Name:

No: Street:

Suburb:

Nature of Request:

* Fallen Tree/ Branch Details:

Exact or closest Location / Intersection / Rural Road # / near Bridge / House / Farm:

Approx size (diameter of trunk / branch):

Does it cover whole or part road? Yes / No (please circle)

Can traffic drive around? Yes / No (please circle)

\\DBK-FS1\data\Engineering\Engineering Administration\Forms\Form WS030 Works & Services Request Form.doc

OFFICE USE ONLY

Priority:

High (within 1 day) Medium (within 1 week) Low (within 4 weeks)

Request Allocated to:

Action:

Forwarded to:

Action:

Completed by (Signature):

Completed date:

Please return completed form to Works Supervisor or Engineering Admin Officer