Applying for Member Assistance To apply for member assistance, please complete the form below. Please enable JavaScript in your browser to complete this form.Please fill out the fields below. All items marked with a * are required in order for the form to submit. Part #1: Type of AssistancePlease select one of the following *UtilitiesCritically Ill Family MemberFuneral AssistanceSpecial AssistanceHardship Additional Information Special Assistance - Payment being made under clause 9 of the WYMAC Hardship - Food Voucher Part #2: Personal DetailsName *FirstLastDate of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Phone *Address *Address Line 1CityState / Province / RegionPostal CodePart #3: Expenses Requested Please provide details of the expenses requested. If you have requested vouchers please enter 'vouchers' or 'food vouchers' in the Item field. Then specify in the field that displays. For example; Woolworths.Item (1) *Who is Being Paid (1) *Amount Requested (1) *Voucher Value (1)Hardship - Food Voucher WoolworthsAdd another item?YesItem (2) *Who is Being Paid (2) *Amount Requested (2) *Voucher Value (2) *Hardship - Food Voucher WoolworthsPart #4: Why Do You Need Help?What has happened recently that caused you to require help? *Please upload any documents or files that are relevant Click or drag files to this area to upload. You can upload up to 5 files. Signature *Clear SignaturePart 5: DeclarationDeclaration Required *I declare all information provided in the above form is correct.Submit