You may inform the Dispute Resolution Adviser of an interruption of supply of a declared petroleum product by completing this form.
| Fields marked with * are required. | |||
| Wholesaler's Details | |||
| *First Name: | *Last Name: | ||
| *Company: | |||
| *Address: | |||
| *State: | *Postcode: | ||
| *Telephone: | Fax: | ||
| Email: | |||
| Required Information | |
| *a) The location of the wholesale facility at which the interruption has occurred | |
| *b) The declared petroleum product affected by the interruption | |
| *c) The expected duration of the interruption | |
| *d) The reason why the interruption has occurred | |
| *Full Name: | |
| *Date (dd/mm/yyyy): | |
