Application For Cards

Instructions

1. Please fill in the information below.
2. An item marked with * is needed.
3. Please draw your signature at the bottom of the screen.
4. Click on “Send Application” once you are ready.
5. You will be redirected to a confirmation page once the application has been sent to us.

Application For Cards

Type of Assistance

Please select one of the following: * The form will change according to the options selected.

Please select one of the following:*(Required)

Personal Details

First Name*(Required)

Last Name*(Required)

Date of Birth*(Required)

Phone*(Required)

Registered home address*(Required)

Suburb(Required)

State(Required)

Postcode(Required)

Expenses Requested

Description of item

Store/Supplier Name

Amount Requested

Click on “+” to add more lines. If you have requested for vouchers, please specify, e.g. Woolworths, Coles.

Why do you need help?

What has happened recently that has caused you to ask for help?*

Please provide any other supporting documents that may be relevant.

Drop files here or

Max. file size: 100 MB.

Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, Max. file size: 8 MB. You would also be able to take a photo of the document using your phone’s camera. If your application relates to attending a funeral, please provide a copy of the funeral notice.

Declaration*

Declaration*(Required)

I declare that the information I have provided in this form is true and correct.*

Signature*

TIP: You can draw your signature in the box below.