Fillable Printable Seniors Card, Seniors Card+go or Seniors Business Discount Card Application Form - Queensland
Fillable Printable Seniors Card, Seniors Card+go or Seniors Business Discount Card Application Form - Queensland
Seniors Card, Seniors Card+go or Seniors Business Discount Card Application Form - Queensland
D D M M
Y Y Y Y
Postcode:
Postcode:
Yes No
Seniors Card, Seniors Card+go or
Seniors Business Discount Card
Application form
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0089 June 2015
Privacy Disclaimer: The Department of Communities, Child Safety and Disability Services is collecting your personal information on this form in order to assess
your eligibility for the Seniors Card, Seniors Card+go or Seniors Business Discount Card. Your personal information will be used by authorised ofcers within the
Department of Communities, Child Safety and Disability Services, Smart Service Queensland and contracted service providers to administer and evaluate the
Seniors Card and Seniors Business Discount Card scheme. Your personal information will be managed in accordance with the Information Privacy Act 2009.
Section 1: Your details (Note: You must be a permanent resident of Queensland)
Title: Mr Mrs Ms Miss Other
Given name:
Middle name:
Family name:
Home address:
Postal address:
(if different from
above address):
Date of birth: Phone:
Email:
Section 2: Special mailings (please tick boxes where appropriate)
I wish to receive additional information about special discount offers from government agencies and
participating businesses.
Section 4: Type of card
I am applying for a:
Seniors Card Seniors Card+go Seniors Business Discount Card
Section 3: Cultural information (optional) (please tick boxes where appropriate)
Please indicate if you identify as:
Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander
Do you speak a language other than English at home? No Yes
(If yes, please specify language spoken)
Please print and complete this form using a ballpoint pen and BLOCK LETTERS.
Once completed, please attach your proof of age (if relevant) and return via:
Post: Card Services
Reply Paid 10817 (no stamp required)
Brisbane Adelaide Street QLD 4000
Fax: 3405 6444
Email: Scan and email to [email protected].au
Alternatively, you can apply for a card online at www.qld.gov.au/seniorscard
Section 6: Your signature
• I conrm I am a permanent resident of Queensland.
• I understand my personal information is managed in accordance with the Information Privacy Act 2009.
• I authorise the Department of Communities, Child Safety and Disability Services to use my personal
information to conrm eligibility with the Department of Transport and Main Roads, Centrelink and/
or Department of Veterans’ Affairs, and concession providers including electricity retailers and other
government agencies.
• I will advise the Department of Communities, Child Safety and Disability Services of any changes in my
circumstances that may affect my eligibility to hold a card.
• I understand that if I am in possession of a Carer Business Discount Card or Companion Card,
the Department of Communities, Child Safety and Disability Services will update my current details for
this card.
• I understand that I can revoke this consent at any time by writing to Card Services, Smart Service
Queensland, Reply Paid 10817 (no stamp required), Brisbane Adelaide Street QLD 4000.
• All information provided on this application is true and correct.
Please sign here:
Date:
Section 5: Your proof of age, address and eligibility for a card
Do you work more than 35 hours per week in paid employment? No Yes
To conrm your details, please provide one of the following:
• Centrelink customer reference number:
See the front of your Pensioner Concession Card, Health Care Card or Commonwealth Seniors Health Card (e.g. 123456789A).
• Department of Veterans’ Affairs file number:
See the front of your Pensioner Concession Card, Commonwealth Seniors Health Card, Repatriation Health Card (Gold or White)
orRepatriationPharmaceuticalBenetsCard(Orange)(e.g.QSM61234A).
If you do not have one of the above cards, please provide one of the following:
• Queensland Driver Licence
• Adult Proof of Age Card number:
If you do not have any proof of age, please contact Card Services on 13 QGOV (13 74 68).
Seniors Card, Seniors Card+go or
Seniors Business Discount Card application form
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0089 June 2015
