Bushfire Disaster Relief Application Form
If you are a Community Pharmacist whose primary dwelling have been partially or fully damaged by the recent bush fires, please complete this and let us know how we can assist you financially for any IMMEDIATE NEEDS **Please note that a secondary reference person is required to verify your claim ** Please read below for further details**
Email address *
First Name
Your answer
Surname
Your answer
AHPRA Registration Number
Your answer
Pharmacy Name
Your answer
Pharmacy Address
Your answer
Postcode
Your answer
Description of partial or full loss to your primary dwelling
Your answer
How can we assist you with your immediate needs ?
Your answer
First Name of Reference Person (The reference person named will be contacted to verify your claim)
Your answer
Surname of Reference Person
Your answer
Phone Number of Reference Person
Your answer
How much funds are you applying for?
Your answer
What will the funds be used for?
Your answer
What can the funds be used for:
* Day to day incidentals for community pharmacists to get back functioning quickly again.* Day to day incidentals for community pharmacists to assist their patients with front of shop items that they require that are not covered by PBS or any other funding.* Day to day incidentals required for community pharmacists to conduct their daily practice prior to waiting for PBS reimbursements to occur.
Thank you for completing this form. You will be contacted shortly on the status of your application for financial support and further bank transfer details will be requested.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy