Name (required field):

Contact Person:

Address (required field):

Email:

Telephone (required field):

Mobile:

Address of graffiti:

Type of structure:

Place a tick in the box next to the type of kit you require:-

Heavy Duty Kit - for use on bare brick, stone and masonry surfaces.

Painted Surfaces Kit - for use on painted or sensitive surfaces such as painted walls, doors,
      fences, gates, signs, posts, perspex, plastic playground equipment.

I have supplied a digital photograph of the graffiti to be removed
      (to attach photo CLICK HERE)   OR

I will provide a photograph of the graffiti to be removed under separate cover.
     (Mail to: Kempsey Shire Council, PO Box 78, West Kempsey, Attention: Linda Young)

Council collects and holds personal information for a number of reasons related to Council business, eg to process applications, to issue rate notices, to process correspondence. When you provide personal information to Council it is used in accordance with privacy laws applicable to Council. Your personal information will only be used for purposes related to the business of Council.

The kit contents will only be used for their intended purpose as specified on the instruction sheet. Kempsey Shire Council holds no responsibility for damage or injury to any person or property. The kit will be used to remove graffiti within the Kempsey Shire Council area.

I agree, as the applicant, that I will abide by the above disclosure and any other conditions imposed by Council.

Click on "I Agree" button to confirm your agreement as stated above and to submit your application.