Application for Water and Waste Concessions for Home Renal Dialysis

Property Owner Details

Owner Name(s) *

Postal Address *

Primary Phone *

Secondary Phone

Email address

Property Information

Property Address *

Property No.Property No. is located on the top right hand side of the rate notice.

Patient Details

Name *

Primary Phone *

Secondary Phone

Postal Address *

Residential Address *

Home Renal Dialysis Machine Information

Doctor or Hospital *

Date Machine was received *

Type of Machine *

Written confirmation form the doctor or hospital must be attached to this application *

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Applicant Declaration

I understand that by completing and signing this application, the water consumption and/or waste service will be granted as per the current Water and Waste Concessions for Home Renaly Dialysis Policy and I declare that I have not lodged another application for this concession under another name. *

I declare that the above details I have provided are true and correct. Mareeba Shire Council does not take responsibility for the supply of incorrect information. *

Applicant Name *

Date *

Applicant Signature *

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Privacy Notice: Mareeba Shire Council is collecting your personal information in accordance with the Local Government Act 2009 in order to process your application. The information will only be accessed by authorised Council 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.