Application for a Victorian Carer Card

Please do not print this page. Carers are welcome to download a PDF of the Application Form [PDF 1.3 MB].

If you can not access or view this form please access our online text only form.

Section one: your details

* Denotes required field.

Your Details

Title MrMsMrsMissDrOther

Other

Given Name *

Middle Name

Family Name *

Gender *

•  Male
•  Female

Date of Birth *

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Residential Street Address

To assist us to process your application include your entire residential street address with unit or house number and street name.

We cannot process your application if you provide a post box or roadside mailbox (RMB) address.

Street *

Suburb *

State *

Postcode *

Daytime phone *

Email address

Postal Address if different from above:

Street

Suburb

Postcode

State

Section two: cultural information (Optional)

Do you identify yourself as an Indigenous Australian?

Do you identify yourself as an Indigenous Australian?

•  Aboriginal
•  Torres Strait Islander

Do you speak a language other than English at home?

Do you speak a language other than English at home? YesNo

If yes, specify

Section three: eligibility

You can confirm your eligibility for a Carer Card by:

• providing your Centrelink Customer Reference Number (CRN) or your Department of Human Services Vendor Number if you receive a carer payment or allowance
• having a health professional verify your eligibility.

If you want to have a health professional confirm your eligibility, please print the Carer Card Application form [PDF 1.3 MB] and submit via post

• Please provide confirmation of your entitlement for a Carer Card by providing the following information.
• Please tick which category of carer you are applying under and fill in the matching field below. *

 I am a Centrelink Carer Payment or Carer Allowance recipient.

CRN (Centrelink Reference Number)

The CRN consists of nine digits and one alphabetic character and can be found on your Centrelink documentation. Please use your own CRN not your child's.

 I am a DHS foster, respite or permanent carer.

DHS Vendor Number

You will find this six digit number on the upper portion of your remittance advice sent to you by the Department of Human Services. Please note, the form will display an error if a number that is not six digits long is entered into this field.

Section four: additional information (Optional)

The Carer Card is a new Victorian Government initiative. The Department of Human Services is collecting additional information to ensure this program is best targeted to the needs of carers and is valued by both carers and participating businesses. Providing this information is voluntary.

Age of the person you provide care for -- Leave Empty --0-1011-2021-3031-4041-5051-6061-7071-8081-9090+

How long have you been a primary carer -- Leave Empty --< 1 year1-3 years3-5 years5-10 years10+ years

The person you provide care for:

•  Has a disability
•  Has a mental illness
•  Frail Aged
•  Requires palliative care
•  Other

Section five: travel entitlements (Optional)

All Carer Card holders are eligible for a Sunday Pass that entitles you to free Sunday travel on metropolitan public transport and regional city town bus services in major Victorian cities.

In addition to the free Sunday Pass, Two Free Off-Peak Travel Vouchers will also be mailed out with your Carer Card. Each can be exchanged for two single or one day return ticket on V/Line-ticketed train and coach services in Victoria.

You may already have a Sunday Pass if you are a Victorian Seniors Card holder, or a Disability Support Pensioner or Carer Payment recipient (who is, under 60 and living in Victoria). Please note, if you are already in possession of a Sunday Pass, another Sunday Pass will not be issued.

If you do not already have a Sunday Pass and would like one supplied free with your Carer Card, please tick the box below.

•  I do not currently have a Sunday Pass but would like one to be supplied free with my Carer Card.

If you have a current Victorian Seniors Card, please include your number here

This is the eight digit number shown on your Seniors Card.

Cardholder Agreement

•  * By ticking this checkbox you agree that the information you have provided is true and correct.

You understand that the Department of Human Services will use your Centrelink Reference Number to verify my eligibility (where applicable).

You will advise the department of any changes in your circumstances that may affect your eligibility to hold a Carer Card.

You understand that the department may use your details to contact you to undertake research, evaluation or review of the Carer Card Program, for example, a survey or questionnaire. This is to ensure continuous improvement of this program. Participation is entirely voluntary.

Privacy and Your Rights

Is this application for a renewal Carer Card?

Please ensure that you complete this section if your current card is about the expire and you would like to apply for a new card.

•  Yes
•  No, this is the first time I have applied for a Carer Card

My Card Number is

•  The applicant confirms that they understand the cardholder agreement above.

Name of the person completing this application *

Date:

21-5-2012

Privacy Statement

The Victorian Department of Human Services 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. The department 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.