Energy and Water Ombudsman Western Australia

Please read information in the Making a complaint section before completing this form. If you still have any queries please ring us on (08) 9220 7588 or Toll Free on 1800 754 004.

Entries marked with * must be completed.

Tell us about your complaint

Are the contact details for the account holder the same as the contact details for the complainant?

Yes No      

If you answered yes, please go to the next section to tell us about the complaint .

If you answered no, please provide the Account Holder's details below before telling us about your complaint.

Surname:

Given Name(s):

Title: Mr Mrs Ms Miss Master Dr Other Select a title

Other Title (please specify):

Email Address:

Street/Postal Address:

Suburb:

State: select a state WA ACT NSW NT QLD TAS SA VIC

Postcode:

Home Telephone:

Mobile Telephone:

Supporting Documentation

If you want to send a relevant document, you can attach a document to this form or send it by post, email or fax:

I am attaching a document to this form

Send this file:

Send this file:

Send this file:

Do you need to send us more than three documents? Yes No

If you need to attach more than three documents, please send your additional documents by email to energyandwater@ombudsman.wa.gov.au and tell us in your email that you have submitted a complaint online.

I will be sending relevant documents that support my complaint by:

Post Email Fax

Your contact details

Please provide us with your contact details below. Please note that your name and address must be provided in order to submit your complaint.

Surname: *

Given Name(s): *

Title: Mr Mrs Ms Miss Master Dr Other Select a title

Other Title (please specify):

Your email address: *

Street/Postal Address: *

Suburb: *

State: select a state WA ACT NSW NT QLD TAS SA VIC

Post Code: *

Home Telephone:

Mobile Telephone:

Representative's Contact Details

If you want someone to represent you regarding your complaint, please give us their contact details below.

Surname:

Given Name(s):

Title: Mr Mrs Ms Miss Master Dr Other Select a title

Other Title (please specify):

Email address:

Street/Postal Address:

Suburb:

State: select a state WA ACT NSW NT QLD TAS SA VIC

Post Code:

Home Telephone:

Mobile Telephone:

Do you require help to access our services?

Do you have an ongoing disability that means you require assistance to access our services?

Yes No      

If yes, please tell us how we can assist you:

Do you need a translator?

Yes No

If yes, please tell us what language you require:

How did you find out about the Energy and Water Ombudsman?

Other information about you

By filling in this information, you will be helping us ensure our services are available to all of the Western Australian community. The personal information you provide is confidential to our office. Any information we release will only identify groups to analyse access by different members within the community. The analysis will not provide any information about individuals. While we would appreciate your responses, you are not required to fill in this part of the form.

Date of birth:

Which gender do you identify as?

Male      Female X (Indeterminate/Intersex/Unspecified)

In which country were you born?

Are you of Aboriginal or Torres Strait Islander origin?

No        Yes

What is the primary language spoken at home?

English    
Indigenous Australian
Other please specify:

Do you have an ongoing disability?

No        Yes

If yes, please indicate what your disability involves:
Sight
Speech
Hearing       
Learning
Use of hands/arms
Use of feet/legs
Long term medical, physical or mental condition
Other
please specify:

Submit your complaint

Please check that the details are correct. To clear all information, click on the 'Reset' button. If you are satisfied with your submission, click on the 'Submit' button to send us your complaint.