CVC Assist Form

CVC Assist Form

We take the privacy and confidentiality of your information seriously. All information provided to us will be handled with the utmost care, confidentiality, and professionalism.
Full Name

First NameLast Name
Member Number
If you do not have a member number, please leave this section blank
Email Address

Confirmation Emailexample@example.com
Phone Number
Please enter a valid phone number.Format: 0400 000 000.
Residential Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Details and Information
Do you have any disciplinary sanctions against you?
Do you have any dependants?
What is the primary reason behind your financial hardship?

Other
Do you have capacity to make some payments, and where possible, enter into a payment plan?
Which one of the following options are you seeking as a form of assistance?
When determining the most appropriate option, CVC may consider a combination of the options.
Are you currently employed?
Do you receive any Centrelink benefits or financial assistance from any other means?
What is your total household income?
Have you sought other means of financial assistance?
Please provide details about your financial circumstances
Please ensure you include all relevant information that you wish CVC to consider.
Please include any other information you feel may be relevant to your application
Upload evidence and documentation

Please ensure any of the following documents are attached alongside your application. This can include a bank statement, Centrelink statements, payslips, letter from a doctor confirming inability to earn income due to disability, injury, illness or caring for sick family member, overdue medical bills/medical expenses, bank notice regarding unpaid overdraft or repossession of mortgaged property, eviction notice, copies of unexpected bills/payments, letter from former employer confirming loss of employment, letter from charitable organisation regarding loss of employment or inability to provide for basic necessities, repossession notice of essential items (e.g., car, motorcycle), funeral expenses, or notice of impending legal action.
Cancelof
This form was easy to complete:
Please verify that you are human
Any misrepresentation or falsification of information may result in your application being rejected and other disciplinary actions as deemed appropriate by CVC.
Signature

This electronic signature will have the same binding effect as a hand written signature.
Should be Empty:

CVC Assist Form

Details and Information