Companion Card interstate transfer form

1. Cardholder details

   1. Title * (Mr, Mrs, Ms, Miss, Other)
   2. Name

      1. Given name *
      2. Family name *
   3. Date of birth * Example: 26/1/2013
   4. Queensland address

      1. Address line 1 *
      2. Address line 2
      3. Address line 3
      4. 1. Town, city or suburb *
         2. State *
         3. Postcode *
      5. Country *
   5. Companion Card number (if known)
2. Which state is the cardholder moving to? *

   • New South Wales
   • Victoria
   • Tasmania
   • Australian Capital Territory
   • South Australia
   • Western Australia
   • Northern Territory
3. Are you: *

   • The cardholder
   • A decision maker
4. Cardholder contact details (If you chose 'The cardholder' above)

   1. Daytime contact number * Home, mobile or work number
   2. Email Example: jane.smart@example.com
5. Decision maker contact details (If you chose 'A decision maker' above)

   1. Title * (Mr, Mrs, Ms, Miss, Other)
   2. Name

      1. Given name *
      2. Family name *
   3. Relationship to cardholder * (e.g. mother, father, carer)
   4. Daytime contact number * Home, mobile or work number
   5. Email Example: jane.smart@example.com
6. Cardholder/decision maker statement *

   1. I give permission for a copy of my Queensland Companion Card information to be released for the purpose of issuing a new Companion Card.
7. Privacy

   1. The information on this form is managed in accordance with the Information Privacy Act 2009. A request for information held by Queensland Government can be made under the Information Privacy Act 2009 (personal information) and the Right to Information Act 2009 (non-personal). For further information about the Information Privacy Act 2009 or the Right to Information Act 2009 visit the legislation website.