Update contact details for your Companion Card

1. 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. 1. Town, city or suburb *
         2. State *
         3. Postcode *
      5. Country *
2. I would like to update my *

   • Residential address
   • Postal address
   • Phone number
   • Decision maker's phone number
3. New residential address (If you chose 'Residential address' above)

   1. Address

      1. Address line 1 *
      2. Address line 2
      3. Address line 3
      4. 1. Town, city or suburb *
         2. State *
         3. Postcode *
      5. Country *
4. 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. 1. Town, city or suburb *
         2. State *
         3. Postcode *
      5. Country *
5. New phone number (If you chose 'Phone number' above)

   1. Phone * Home, mobile or work number
6. 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
7. Are you *

   • The cardholder
   • A decision maker
8. 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
9. 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.
10. 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.