Medical Fund Application Form

NAME:*
FIRST NAME: MIDDLE NAME: SURNAME:
DATE OF BIRTH:*
ADDRESS:*
STREET: SUBURB: POSTCODE:
EMAIL:*
MOBILE:*
DETAILS OF APPOINTMENT*
Please provide details of the appointment.
QUOTE FROM SUPPLIER*
Please upload a copy of your quote. You can upload a PDF, JPEG or Microsoft Word document.
Drop files here or

Accepted file types: pdf, jpg, doc, docx, Max. file size: 10 MB.
Application Declaration
I have read and understand the Policy and I declare all information supplied to be true and correct. I agree that my typed name below can be used as a digital representation of my signature to that fact.
TO ACCEPT, TYPE YOUR NAME BELOW*
For any application enquiries please contact the office on 08 9997 3444 or email members@wajarri.com.au

We pay our respects to Wajarri Elders past and present and thank the community for allowing us to serve them as directors of Winja Wajarri Barna Limited. We are excited by the opportunity to deliver the programs set out in this website and to act as good custodians of Wajarri community assets. As Directors we aim to achieve the highest standards of governance and intend to work with our member, Wajarri Yamaji Aboriginal Corporation, to deliver on our joint mission “Engaging, empowering and investing in Wajarri Yamaji Peoples’ future.”

Medical Fund Application Form

Medical Fund Application Form

Application Declaration

Members

Viewers Discretion

Traditional owners are warned that the following may contain names/images of deceased persons.