Companion Card—Industry affiliation form

1. Service profile Please provide the following details about ALL the services/venues/events/activities operated by your organisation (including interstate) where the Companion Card will be recognised.

   1. Service 1

      1. Name of service/venue/event/activity *
      2. Phone *
      3. Website
      4. Address

         1. Address line 1 *
         2. Address line 2
         3. Address line 3
         4. 1. Town, city or suburb *
            2. State *
            3. Postcode *
      5. Add a second service
   2. Service 2

      1. Name of service/venue/event/activity *
      2. Phone *
      3. Website
      4. Address

         1. Address line 1 *
         2. Address line 2
         3. Address line 3
         4. 1. Town, city or suburb *
            2. State *
            3. Postcode *
      5. Add a third service
   3. Service 3

      1. Name of service/venue/event/activity *
      2. Phone *
      3. Website
      4. Address

         1. Address line 1 *
         2. Address line 2
         3. Address line 3
         4. 1. Town, city or suburb *
            2. State *
            3. Postcode *
      5. Add a fourth service
   4. Service 4

      1. Name of service/venue/event/activity *
      2. Phone *
      3. Website
      4. Address

         1. Address line 1 *
         2. Address line 2
         3. Address line 3
         4. 1. Town, city or suburb *
            2. State *
            3. Postcode *
      5. Add a fifth service
   5. Service 5

      1. Name of service/venue/event/activity *
      2. Phone *
      3. Website
      4. Address

         1. Address line 1 *
         2. Address line 2
         3. Address line 3
         4. 1. Town, city or suburb *
            2. State *
            3. Postcode *
      5. Add a sixth service
   6. Service 6

      1. Name of service/venue/event/activity *
      2. Phone *
      3. Website
      4. Address

         1. Address line 1 *
         2. Address line 2
         3. Address line 3
         4. 1. Town, city or suburb *
            2. State *
            3. Postcode *
      5. Add a seventh service
   7. Service 7

      1. Name of service/venue/event/activity *
      2. Phone *
      3. Website
      4. Address

         1. Address line 1 *
         2. Address line 2
         3. Address line 3
         4. 1. Town, city or suburb *
            2. State *
            3. Postcode *
      5. Add a eighth service
   8. Service 8

      1. Name of service/venue/event/activity *
      2. Phone *
      3. Website
      4. Address

         1. Address line 1 *
         2. Address line 2
         3. Address line 3
         4. 1. Town, city or suburb *
            2. State *
            3. Postcode *
      5. Add a ninth service
   9. Service 9

      1. Name of service/venue/event/activity *
      2. Phone *
      3. Website
      4. Address

         1. Address line 1 *
         2. Address line 2
         3. Address line 3
         4. 1. Town, city or suburb *
            2. State *
            3. Postcode *
      5. Add a tenth service
   10. Service 10

       1. Name of service/venue/event/activity *
       2. Phone *
       3. Website
       4. Address

          1. Address line 1 *
          2. Address line 2
          3. Address line 3
          4. 1. Town, city or suburb *
             2. State *
             3. Postcode *
2. Business and organisation details

   1. Business name *
   2. Physical address

      1. Address line 1 *
      2. Address line 2
      3. Address line 3
      4. 1. Town, city or suburb *
         2. State *
         3. Postcode *
   3. Is your postal address different from the above address? *

      • Yes
      • No
   4. Postal address (If you chose 'Yes' above)

      1. Address line 1 *
      2. Address line 2
      3. Address line 3
      4. 1. Town, city or suburb *
         2. State *
         3. Postcode *
3. Contact person

   1. Title *
   2. Name

      1. Given name *
      2. Family name *
   3. Phone *
   4. Position *
   5. Email *
   6. Fax
   7. Are you the authorised representative for this organisation? *

      • Yes
      • No
   8. Authorisation (If you chose 'Yes' above)

      1. • I understand and accept the Companion Card program affiliate statement and the Companion Card affiliate terms and conditions.
   9. Please provide the contact details for the authorised representative (If you chose 'No' above)

      1. Name of authorised representative *
      2. Position *
      3. Phone *