Update contact details for your Companion Card

Cardholder details
1. Title * (e.g. Mr, Mrs, Ms, Miss, Other)
2. Name
  1. Given name *
  2. Family name *
3. Date of birth * Example: 26/1/2013
4. Companion card number (if known)
5. Address currently recorded
  1. Address line 1 *
  2. Address line 2
  3. Address line 3
  4. Town, city or suburb *
    
    State *
    
    Postcode *
  5. Country *
I would like to update my *
- Residential address
- Postal address
- Phone number
- Decision maker's phone number
New residential address (If you chose 'Residential address' above)
1. Address
  1. Address line 1 *
  2. Address line 2
  3. Address line 3
  4. Town, city or suburb *
    
    State *
    
    Postcode *
  5. Country *
New postal address (If you chose 'Postal address' above)
1. Postal address
  1. Address line 1 *
  2. Address line 2
  3. Address line 3
  4. Town, city or suburb *
    
    State *
    
    Postcode *
  5. Country *
New phone number (If you chose 'Phone number' above)
1. Phone * Home, mobile or work number
New formal or informal decision maker phone number (If you chose 'Formal or informal decision makers phone number' above)
1. Phone * Home, mobile or work number
Are you *
- The cardholder
- A decision maker
Decision maker details (If you chose 'A decision maker' above)
1. Title * (e.g. Mr, Mrs, Ms, Miss, Other)
2. Name
  1. Given name *
  2. Family name *
3. Relationship to cardholder *
4. Daytime contact number * Home, mobile or work number
Cardholder/decision maker statement *
1. I certify the information I have provided is true and correct. I understand it is an offence to provide false information on this form.
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.

Last updated:: 10 September 2014