Page 1

QTU Member Application for QTU Natural Disaster Relief Surname: Given names: Address:

Telephone: Home

Mobile

Email: Employee/Member No (if known): Brief description of circumstances. Extent of damage and losses to your principal place of residence: Amount of assistance sought: $ What insurance cover do you have? What other relief is being sought? Arrangements for payment: Bank: BSB: Account number: In submitting this claim I verify that the information provided above is true and correct: Member Union Representative to witness where possible Signed: Date:

/

/

Please note: Payment will be made upon assessment of application. Applications may be made: • Online: the relief payment will be made upon assessment of the online application, however a signed copy of the application should be subsequently sent to the QTU; or • Other: Email: send a scanned copy of the application to qtu@qtu. asn.au (Subject: Natural Disaster Relief); Fax: 07 3512 9050; or Post: QTU, PO Box 1750, Milton BC 4064 • Funds transferred by EFT are usually available overnight

/

/

Office use only Amount approved Signed

Date

/

Authorised by Graham Moloney, General Secretary, Queensland Teachers’ Union, 21 Graham St. Milton Q 4064 - April 2014

/

Natural disaster applicationform april2014  

http://www.qtu.asn.au/files/2213/9743/2825/Natural_Disaster_Applicationform_April2014.pdf

Read more
Read more
Similar to
Popular now
Just for you