Carer Card Business Registration Form

Thank you for your interest in registering your business to participate in the Carer Card Program. To get started, complete all required information in the fields below.
* fields are mandatory

Business Details

Registered name *

ABN *

Trading name *

Business description *

Business street address *

Suburb *

State *

Postcode *

Phone number *

Website address

Only fill in the below fields if not the same as above.

Business postal address

Suburb

State

Postcode

Business Contact Details

If more than one outlet, please email
details to carercard@dhs.vic.gov.au

Title *

First name *

Surname *

Position *

Business phone *

Business fax

Directory Address

Directory address

Suburb

State

Postcode

Provide your logo You may provide your business logo for the printed and online directory.

Format: JPEG, GIF, PNG File Size: 100KB maximum.

Please include a message to Carers (optional). For example: �John Smith�s Butcher is committed to recognising Carers in our community, come see us today!�. Maximum 20 words.Business message Maximum 150 characters

Discount or offer, please indicate discount as it will appear in the Carer Card directory.

Select a percentage discount or the option for Other if your offer isn't a percentage and place any further details in the text entry box marked Offer Details.

Offer Details

Please note that final agreement on the terms of the discount or offer is at the absolute discretion of DHS in accordance with the Terms and Conditions.

I understand and acknowledge that:

The information provided in this application is true and complete to the best of my knowledge
This application forms a legal document and penalties exist for providing false or misleading information

I have read and agree to the full Terms and Conditions for participation in the Carer Card Program. *

First name of the person completing this application *

Last name of the person completing this application *

Date: 23-2-2012

Privacy Statement

The Victorian Department of Human Services (DHS) is collecting information on this form to assist in the administration of the Carer Card program. Personal information will not be disclosed to any third parties without your consent or unless required by law. DHS may confirm business information with the Office of Fair Trading to assist with the assessment of your registration. Your business addresses and telephone numbers may be accessed by the public through the Carer Card website and directory. Personal details are protected by the Information Privacy Act 2009.