Fillable Printable Seniors Card Application and Replacement Card Form - Western Australia
Fillable Printable Seniors Card Application and Replacement Card Form - Western Australia
Seniors Card Application and Replacement Card Form - Western Australia
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WA SeniorsCard Application and Replacement Card Form
Government of Western Australia
Department of
Local Government and Communities
Eligibility requirements for the WA Seniors Card:
1. You meet the age conditions, as listed below:
Date of birth Age to qualify for a WA Seniors Card
Before 1 July 1955 60 years
1 July 1955 to 30 June 1956 61 years
1 July 1956 to 30 June 1957 62 years
1 July 1957 to 30 June 1958 63 years
1 July 1958 to 30 June 1959 64 years
After 30 June 1959 65 years
2. You are a permanent resident of Western Australia
To be eligible for a WA Seniors Card, you must be a permanent resident of Western Australia.
3. You are working 25 hours or less per week
You can work 25 hours or less per week, averaged over a 12 month period and still be eligible for a
WA Seniors Card.
Use this form to apply for a new or replacementWA Seniors Card.
Page 1
Terms and Conditions
Please read the Terms and Conditions for full eligibility requirements and WA Seniors Card holder’s
responsibilities before completing this application. The Terms and Conditions are available at
www.seniorscard.wa.gov.au or can be obtained by contacting the WA Seniors Card Centre on
(08) 6551 8800 or 1800 671 233 (country free call).
Part 1: Identication
Legible photocopies must be attached to this application form.
You must provide either;
ONE Category
A document
OR at least ONE
Category B document
that includes a
photograph.
Your initial document
from this group will be
awarded 40 points, any
additional documents
are awarded 25.
All documents in
this group attract 25
points. Only one card
from each institution
may be counted.
Australian Birth Certificate 70 N Y
or Birth Card
(extracts are not acceptable)
Australian Passport 70 N Y
(current or expired within the last
two years but not cancelled)
Australian Citizenship Certificate 70 N Y
International Passport 70 N Y
(current, not expired or cancelled)
Photo Card 70 Y Y
Issued by the Department of Transport
WA Drivers Licence 40 Y Y
Other licences issued under 40 Y Y
Australian Law
State or Federal Government 40 N N
Employee Identity
Tertiary Education 40 N N
Institution Identity
Department of Veteran 40 N N
Affairs Card
Centrelink or Social 40 N N
Security Card
Medicare Card 25 N N
Council Rates Notice 25 Y N
Property Lease/Rental Agreement 25 Y N
Property Insurance Papers 25 Y N
Motor Vehicle Registration 25 Y N
or Insurance Documents
Professional or Trade Association Card 25 NN
Utility Bills (e.g. Telephone, Gas) 25 Y N
Credit/Account Card 25 N N
Bank Statements/Passbook 25 Y N
Page 2
New application - To apply for a new WA Seniors Card, 100 points of identification including
a photograph is required. The combination of documents supplied should as a minimum
show evidence of your full name, date of birth and permanent address being in Western
Australia. Legible photocopies of the identification must be attached to this application form.
If your name is different from your identification, the following documents can be provided:
• Marriage Certificate • Divorce Papers • Change of Name Certificate from the Registrar General.
These documents do not contribute to the 100 point identification score and only verify your name change.
WA Date
Category A Identification Points Residency of Birth
Category B
Category C
Attach
legible
photocopies
Acceptable
Identication
documents
The following identication
can be used to prove:
Title
Your details
Address
Postal
Address
(if different
from above)
Contacts
First name Middle name(s)
Address
Suburb
StatePostcode
MobileHome telephone
Postal address
StatePostcode
Email
Ofce use only
Mr Mrs Miss Ms
Other (please specify)
Surname
WA Seniors Card number
Entered
...................................
Checked
...................................
Date of BirthGender
New application
Replacement card
Update details
Part 2: Personal Details
Please tick the relevant options:
Page 3
How many hours per week
would you typically work?
What is your occupation?
Are you a holder of a visa? What subclass visa do you hold?
No Yes
No Yes
Would you like to receive occasional information relevant to seniors?
Disclaimer:The Department of Local Government and Communities will not share your information with any not-for-profit or
commercial entities.
Do you have one of the following cards issued by the Department of Human Services (Centrelink)?
No Yes (if yes please provide your Customer Reference Number below)
Pensioner Concession Card CRN:
Commonwealth Seniors Health Card CRN:
Do you have one of the following cards issued by the Department of Veterans’ Affairs?
No Yes (if yes please provide your Department of Veteran’s Affairs number below)
Pensioner Concession Card DVA File Number:
Commonwealth Seniors Health Card DVA File Number:
DVA Health Card - includes Gold, White and Orange card:
This section MUST be completed in order to apply for a new or replacement card.
Attach Proof
of ID (new
applications
only)
The following identication
can be used to prove:
Part 3a: Checklists
Before you send off your application, use this section to check that your
application is complete.
Printed in May 2015.
Material number: 8839730
DLGC SO131-May15
Please return this form and
attachments in an envelope to:
WA Seniors Card Centre
Locked Bag 3
Perth Business Centre
WA 6849
Page 4
Remember to:
Attach photocopies
of the required identication
documents
How to contact
the WA Seniors
Card Centre
Telephone: (08) 6551 8800
Country WA: 1800 671 233
Fax: (08) 9226 4745
Email: [email protected]v.au
Web: www.seniorscard.wa.gov.au
WA Seniors Card Centre
Level 2, 140 William Street,
Perth, Western Australia
(Entry from Murray Street
Mall after Perth underground)
Part 3b: Declaration signature
Your signature
• I agree to the Terms and Conditions
• I declare that the information I have provided in this application form is true and correct to
the best of my knowledge.
Signature of applicant
Date
Checklist – new cards
I meet the eligibility requirements
My personal details are correct
I have attached copies of identification
for 100 point ID check,including proof
of WA residency and age
Checklist – replacement/update
I meet the eligibility requirements
My personal details are correct
* Your card will be sent to your current
address unless otherwise notified of a
change in this application form
If your circumstances have changed, you must notify the WA Seniors Card
centre immediately.
