Birmingham City Council
Title Mr Mrs Miss Ms Dr Rev Sir
First Name *
Last Name *
Email *
Phone *
Mobile Please provide your mobile number if you wish to receive text updates
Property name and number *
Street *
District
City or town *
Postcode *
Date of Birth In the format DD/MM/YYYY
What needs to be repaired? * for example: door, radiator...
Where is the repair needed? * for example: upstairs bathroom, kitchen...
Are you a leaseholder? If so, you may be charged for the repair. Refer to the terms of your lease for details, or contact the Leasehold Team on 0121 675 6718. Yes
Please explain how the damage was caused? * for example: local kids broke my fence, my tap has started leaking
Do you have a crime reference number? If so, please give it
Can you cope while waiting for this repair to be carried out? If not, please explain why. Please note, some non-urgent repairs can take up to 30 days.
Appointment Time * Please choose an appointment time. Please select Morning - between 8am and 12 noon Afternoon - between 12 noon and 5pm All day - between 8am and 5pm School run - between 9.30am and 3pm
State any dates when the repair cannot be done for example: because you will be on holiday
Special Circumstances For example, tell us if we will need to knock loudly because you have a hearing impairment, or if we should allow you longer to answer your door.
Please tick to confirm * I confirm that this request is not for an urgent repair
Please tick to confirm * I understand that I will be charged for the repair work if the damage was caused by myself or a visitor to my home