Surname:

Given names:

Address:

Telephone: Home Mobile

Email:

Employee/Member No (if known):

Brief description of circumstances. Extent of damage and losses to your principal place of

residence:

Amount of assistance sought: $

What insurance cover do you have?

What other relief is being sought?

Arrangements for payment:Bank:

BSB:

Account number:

In submitting this claim I verify that the information provided above is true and correct:Member Union Representative to

witness where possibleSigned:

Date: / / / /

QTU Member Application for QTU Natural Disaster Relief

Authorised by Graham Moloney, General Secretary, Queensland Teachers’ Union, 21 Graham St. Milton Q 4064 - April 2014

Please note: Payment will be made upon assessment of application. Applications may be made:• Online: the relief payment will be made upon assessment of

the online application, however a signed copy of the application should be subsequently sent to the QTU; or

• Other: Email: send a scanned copy of the application to qtu@qtu.asn.au (Subject: Natural Disaster Relief); Fax: 07 3512 9050; or Post: QTU, PO Box 1750, Milton BC 4064

• Funds transferred by EFT are usually available overnight

Office use onlyAmount approved

Signed

Date / /