Request a replacement Companion Card

1. Reason for replacement *

   • Lost
   • Damaged
2. 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. Residential 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 *
3. Are you: *

   • The cardholder
   • A decision maker
4. Cardholder contact details (If you chose 'The cardholder' above)

   1. Is your postal address different from your residential address? *

      • Yes
      • No
   2. Postal address (If you chose 'Yes' 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 *
   3. Daytime contact number * Home, mobile or work number
5. Decision maker contact 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 * Optional hint for the text field
   4. Daytime contact number * Home, mobile or work number
6. 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.
7. 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.