Replacement Card Form: – Seniors Victoria

Reason for Replacement *

Personal Details

Title *

First name *

Last name *

Date of birth *//

Card Number (if available)

Contact Details

Phone number *

Email address *

Email

Confirm Email

Residential address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Postal address different to the residential address

Postal address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Submit Application

Total

Price: $ 19.00

Debit / Credit Card Details *

Card

Name on Card

I have read and accept the Terms and Conditions of Service.

Your Declaration and Important Information

I confirm that:
• I am 60 years of age or over or will be within 3 weeks.
• I am a permanent resident of Australia.
• I am residing in Victoria.
• My working hours (including self-employment) that I have provided are true.
• The information supplied is, to the best of my knowledge, accurate and complete.
• I can provide evidence that I am entitled to a Seniors Card if requested.

By submitting this form, I declare that seniorsvictoria.com is authorised to submit a Seniors Card or Seniors Business Discount Card application to the Victorian Department of Health and Human Services (DHHS) on my behalf and if necessary, submit a replacement card request for a Seniors Card or Seniors Business Discount Card. I understand that seniorsvictoria.com will utilise the information supplied by me in this form to apply for a Seniors Card or Seniors Business Discount Card, and if necessary, will use my information to request for a Replacement Card. I confirm that I have received the consent of the individual referred to in this application form, to the submission of their personal information contained in this form to seniorsvictoria.com and to the Victorian DHHS to process this application. I verify that the information supplied is, to the best of my knowledge, accurate and complete.