Seniors Fund Application Form

NAME:*
FIRST NAME: MIDDLE NAME: SURNAME:
DATE OF BIRTH:*
Select your age bracket*
ADDRESS:*
STREET: SUBURB: POSTCODE:
EMAIL:*
MOBILE:*
PROOF OF RESIDENTIAL ADDRESS WHEN APPLYING FOR HOUSEHOLD EXPENSES
Please upload your Proof of Residential Address. 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.
PROOF OF VEHICLE OWNERSHIP WHEN APPLYING FOR VEHICLE EXPENSES
Please upload your Proof of Vehicle Ownership. 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.
QUOTES FROM SUPPLIER WHEN APPLYING FOR HOUSEHOLD ITEMS / LIVING AIDS
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

Application Declaration