Home Maintenance Service Request | COTA NT | Voice for Territory Seniors

Name*

First Last

All fields marked with an asterix (*) must be completed

COTA NT Membership Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (landline)

Phone (MOBILE)

Email

Contacting You

We advise the Home Maintenance team to leave a message if you aren't able to take a call. If you cannot hear or understand the message clearly, call our friendly Head Office team on 08 8941 1004.

Best Day / Time to Contact You

Mornings
Afternoons
Any time

Preferred Contact Method

Call LANDLINE phone
Call MOBILE phone
Send SMS
Email

Service Information

Type of Maintenance Requested (please check a box)

Description of problem/ issue*

Please provide a short description of your maintenance request so we can prioritise the most urgent.

Is this a rental property?*

Yes — Please contact the Property Owner
No

Do you own this property?

Yes
No

Does the maintenance require body corporate approval?

Yes — Please contact the Body Corporate
No

Are you registered with My Aged Care under CHSP?

Yes
No

Will you be claiming reimbursement through your insurance?

Yes
No

Home Maintenance Request Form

Contacting You

Service Information