Incident

*- indicates required field.

First name (optional)

Last name (optional)

Organisation name (optional)

Contact email (optional) HelpText

Contact address (optional)

Contact phone no. (optional)

Would you like Waikato Regional Council to keep your details confidential from any other involved party in relation to this matter *

Yes

Do you want to be notified of the outcome of this matter *

If Yes, ensure at least one method of communication is provided

Yes

If Yes, ensure at least one method of communication is provided

Subject *

What happened, where, time/date, who was involved *

When did you first notice the problem *

Time (optional)

Address of incident Location *

Indicate the location of the incident on the Map by zooming in and moving the pin to the desired location. (optional)

Please upload supporting files if any (optional) HelpText

(avi, doc, docx, gif, jpeg, jpg, m4v, mov, mp3, mp4, msg, pdf, png, txt, wmv, xls or xlsx)

Upload

(AVI, DOC, DOCX, GIF, JPEG, JPG, M4V, MOV, MP3, MP4, MSG, PDF, PNG, TXT, WMV, XLS or XLSX)

Their first name (optional)

Their last name (optional)

Their organisation (optional)

Their address (optional)

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Request Type (optional)

CheckContactMethod (optional)

Incident Details (optional)