Application for submission to St Paul’s Hostels

1. PERSONAL DETAILS

Surname *

Title *

Given Names *

Preferred Names *

Date and year of birth *

Present age *

Religion *

Town and State

Country of birth

If born overseas, date of arrival in Australia

Are you a naturalised Australian? *

Status *

Full name and current address of spouse

Briefly, give reasons for applying for accommodation *

2. CURRENT RESIDENCY DETAILS

Present Address *

Postcode *

Phone *

Are you *

Give details *

Is this *

Give details *

3. FAMILY CONNECTIONS

Names, addresses and phone numbers of children still living

Name *

Address *

Phone *

Details of responsible person to contact in an emergenc

Title *

Address *

Postcode *

Phone *

Mobile

Email *

Relationship of responsible relative/person to applicant *

4. ADMINISTRATIVE DETAILS

A

Name of doctor *

Address *

Postcode *

Phone *

Pension Entitlement number *

Exp *

Veteran Affairs number *

Medicare number *

Exp *

B

Are you a member of a hospital fund? *

Name of fund *

Schedule *

C

Have you made a Will?

Name

Address

Postcode

Phone

D

Does anyone have

House
Unit
Flat
Holiday house
Other

Details

If no, when did you last own a home, if at all?

If you own a home and do not live in it, who is occupying It?

If you own a home, do you propose to sell it?

Home (Estimated Current Market Value)

Other real estate

Motor car

Make/model

Year

6. SAVINGS

Cash held by you

Money in bank

Building society

Credit union

Other investments, e.g. bonds, shares, etc

Money owing to you

Any other assets with a current value of $3,000 or more; e.g. jewellery, caravan, etc.?

Mortgage amounts still owing

NOTE: If you have assets more than two and a half times the annual pension, you will be required to pay an Accommodation Bond. Accommodation Bonds are subject to refund provisions.

Are you a *

Full Pensioner
Part Pensioner
None Pensioner

(Name in block letters) ....... *

of (Address) *

state that the information given in this application is true and correct.

.......state that the information given in this application is true and correct.

Correct

Signature *

Draw your signature here

Date

Please remember that a false statement on a Statutory Declaration could lead to a charge of Perjury.

Please provide the necessary back-up papers to prove the above statements, e.g. bank books; rate assessment notice, etc. for the last two years.

When a prospective resident has confirmed an admission date, but fails to enter the Facility, an administrative fee will be charged. The amount will be calculated in accordance with guidelines set by the Government.

An administrative fee is also payable when resident enters the Facility.

Application for admission to St Paul's Hostel

St Paul's Hostel

Please return within 14 days to the above address.

1. PERSONAL DETAILS

2. CURRENT RESIDENCY DETAILS

3. FAMILY CONNECTIONS

Names, addresses and phone numbers of children still living

Details of responsible person to contact in an emergenc

4. ADMINISTRATIVE DETAILS

A

B

C

D

E

Give details of anyone looking after your affairs

F

Name and address of solicitor

G

Give details if you have funeral arrangements

H

If not, do you have any preference for a funeral director?

5. ASSETS

6. SAVINGS

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