ACT Companion Card Program - ACT Companion Card

ACT Companion Card

Request for Information

Disability ACT is in the process of setting up the Companion Card program and has not commenced accepting cardholder applications.

Application forms and program information packs will be available in early September. To receive an info pack, please fill out the online Request for Information form below.

Alternatively, you can download and post the completed form to us.
Request for Information Form (PDF) 51KB
Request for Information Form (RTF) 72KB

Register of Interest

To register your interest in the Companion Card please fill out the form below.

You will be sent an information pack once the Companion Card program commences accepting applications.

* denotes mandatory field

Contact Details

First Name: *
Last Name: *
Organisation:
Postal Address:*
Suburb: *
State/Territory: *
Postcode: *

If you would like to receive program updates via email, please provide your email address:

Email:

Interest category

Please let us know if you are:

A person with a disability interested in applying for the Companion Card
A family member, friend or carer of a person with a disability
A disability support organisation, government agency or health professional
A business or venue operator interested in finding out more about becoming an affiliate
Other

Please specify:

Comments:

(Do you require more than one copy of the information pack? Alternative formats?)

* denotes mandatory field

Use of Personal Information Collected

Any personal information you choose to provide will only be used for the purpose for which it was provided and will not be disclosed to other persons or organisations without your prior consent, except where authorised or required by law in accordance with the Guidelines for Federal and ACT Government World Wide Websites developed by the Australian Privacy Commissioner.

For additional information, please refer to the DHCS web site Privacy Statement

Last Updated ( Friday, 22 October 2010 )