Brokerage Maintenance and Domestic Assistance
Type of Referral
*
Please Select
Home Maintenance
Garden Maintenance
Spring Clean
Domestic Assistance
Consumer Details
Consumer Details
Title
*
Mr
Mrs
Miss
Ms
First Name
*
Surname
*
Preferred Name
Date Of Birth
*
/
Day
/
Month
Year
Date Picker Icon
Street Address
*
Suburb and Postcode
*
Postal Address (if different from above)
Suburb and Postcode
Phone
*
Dwelling Details
Please Select
High Set
Low Set
Other
Residency Type
*
Private Residence (Client or Family Owned/Purchasing)
Private Rental
Public Rental
Independent Living Unit
Owner / Landlord / Agency Name
*
Owner / Landlord / Agency E-Mail
*
Owner / Landlord / Agency Phone Number
*
Package Details
Does the Person have a Home Care Package or STRC?
*
Please Select
HCP Level 1
HCP Level 2
HCP Level 3
HCP Level 4
STRC
SDA
HCP/STRC Provider
*
HCP/STRC Phone Number
*
HCP/STRC Email
*
example@example.com
HCP/STRC Contact Person
*
STRC Start Date
*
-
Month
-
Day
Year
Date
STRC End Date
*
-
Month
-
Day
Year
Date
Works Required
Priority Rating for Completion of Work
*
Please Select
High
Medium
Low
ASAP
Work Requested
*
Documents / Photos Attached
Browse Files
Drag and drop files here
Choose a file
Cancel
of
All work requested has been discussed with and has the consent of the consumer and/or their career. Consumer is aware of the $100.00 cancellation fee should the requested work not proceed or if the referral is cancelled 24 hours after submission.
*
Yes
No
Pre-Approved Amount
Quote Required
*
Yes
No
If you require items to be quoted separately please submit separate referrals for each item.
Please Note: Quotes are only valid for 30 days. $100.00 cancellation fee applies if quote expires
*
I Understand
Is a purchase order/service request required *
*
Yes
No
Please upload purchase order/service request (if required)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Additional details or advisements (if required)
Name of Person Submitting Referral
*
Contact Phone Number
*
Email Address
*
example@example.com
Submission Date
*
-
Day
-
Month
Year
Date
Please verify that you are human
*
Submit
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