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Name*
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Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I wish to apply for a subsidy for the following item of equipment:
This item will assist me to:
Suppliers name*
Name
Address*
Address City State / Province / Region ZIP / Postal Code
Phone*
Email*
Enter Email Confirm Email
Position in the Organisation
Member endorsement*
- I have understood the equipment subsidy guidelines and believe this application meets these guidelines. I will be contributing the amount mentioned below and wish to apply for the subsidy
- I have undertaken to research the best option for my current circumstances. It is my opinion, in conjunction with opinion of other professional sources as required, that this equipment is: 1. appropriate to my current needs, 2. will be of benefit in assisting me to gain or maintain independence, 3. I have or will gain proficiency in its use and am able to access training if needed.
My contribution for the purchase of the equipment $*
Subsidy amount applied of $*
Signed*
Date*
Date Format: MM slash DD slash YYYY
Once you submit your form by using the button below you should be presented with a confirmation page. If you are not presented with a confirmation page, there is an error in your form. Errors will be highlighted.
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Approved by Member Services Officer
Approved by Manager
Name
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Date
Date Format: MM slash DD slash YYYY