Applying for Member Assistance - Wirlu-Murra Yindjibarndi Aboriginal Corporation

Please fill out the fields below. All items marked with a * are required in order for the form to submit.

Part #1: Type of Assistance

Please select one of the following *

Additional Information
Special Assistance - Payment being made under clause 9 of the WYMAC
Hardship - Food Voucher

Part #2: Personal Details

Name *

First

Last

Date of Birth *//

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Part #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 Woolworths

Add another item?

Yes

Item (2) *

Who is Being Paid (2) *

Amount Requested (2) *

Voucher Value (2) *

Hardship - Food Voucher Woolworths

Part #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 *

Part 5: Declaration

Declaration Required *

I declare all information provided in the above form is correct.