Request a replacement Companion Card

Reason for replacement *
- Lost
- Damaged
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. Town, city or suburb *
    
    State *
    
    Postcode *
  5. Country *
Are you: *
- The cardholder
- A decision maker
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
    Address line 1 *
    
    Address line 2
    
    Address line 3
    
    Town, city or suburb *
    
    State *
    
    Postcode *
    
    Country *
3. Daytime contact number * Home, mobile or work number
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
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.
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.

Last updated:: 10 September 2014