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Authorise access (Commercial)
Authorise access (Commercial)
Formstack Form
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--select an item--
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*
To be completed by the owner only.
You will need to complete a new form for each individual/party you want authorised.
Fields marked with * are required fields
Coliban Water’s approach to safeguarding the personal information collected via this form is set out on the
Privacy
page on our website.
Owners Details:
Account Name
*
ABN/ACN:
Customer Number:
*
You will find your Customer Number (C-XXXXXXXXX) at the top right-hand side of the bill. Enter numbers only.
Street
*
Suburb
*
State/Territory
*
Postcode
*
Contact Number:
*
Email Address:
*
If this change applies to more than one account, please list additional Customer Numbers and / or Property Address(es):
Authorised Party
Would you like to authorise the 'care of' party onto your Coliban Water account?
*
Yes
No
--select an item--
Yes
No
If you would like to authorise someone other than a listed account holder to access and make enquiries regarding your Coliban Water account, tick yes.
Is the Authorised Party (Third Party)
An Individual
An Organisation
--select an item--
An Individual
An Organisation
Details
Organisation Name:
Organisation ABN/ACN:
Representative First Name:
Representative Last Name:
First Name:
Last Name:
If the authorised party is an Organisation we require a contact name for the business.
Date of Birth:
Contact Number:
*
Email Address:
*
Postal Address:
Please be advised the name on your Coliban Water account will still remain on your water bill the chosen third party will be the care of.
Postal Street:
*
Postal Suburb:
*
Postal State:
*
Postal Postcode:
*
Postal Country
*
Acknowledgement
I understand and acknowledge that:
• I have requested Coliban Water commence sending all future accounts to the property address rather than the landlord/property owner's address.
• I have made the tenant aware that future accounts will be mailed to them following this request.
•
I understand that I am legally responsible for the account under the Water Act 1989.
Acknowledgement:
*
Tick to confirm
Tick to confirm
I understand and acknowledge that:
• The information provided in this application is true and complete to the best of my knowledge
• Coliban Water may refuse this application if it becomes evident that any information or supporting documents provided are incomplete or false
• This authority can be revoked at the discretion of Coliban Water should either of the authorised parties fail to respond to a reasonable written request from Coliban Water within a reasonable a period of time.
• I, the account holder/s, also authorise the person and or organisation specified to do any act and receive any information from Coliban Water relating to the administration of the water account specified and for this purpose consent to the disclosure of any personal information by Coliban Water to the authorised person or organisation.
• This arrangement will remain in place until such time as Coliban Water are advised of any changes to this arrangement via the completion of a new form.
Acknowledgement:
*
Tick to confirm
Tick to confirm
clear
Typed
Drawn
I agree to terms and services
Email
Full Name of Applicant
*
Date
*
Full Name of Applicant
*
Date
*
Email Billing
Please tick this box if you would like to have your bills emailed to you.
Please tick this box if you wish to opt out of additional email communications
Please tick this box if you want to receive a confirmation email when the form is submitted.
Confirmation Email Address
Captcha
*
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