Application For Elders Program for Current Members
In order to complete the form, all sections must be filled in! Please contact YSRC if you need guidance on a specific section.
Section 1: Contact Details for CURRENT MEMBERS turning 60 years of age
Membership number if known
*
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Exsisting member:
*
I confirm I am an exsisting member of Yamatji Southern Regional Corporation
60+ years old
*
I confirm I am 60+ years of age this financial year and would like to apply for the ELDERS GIFT CARD program valued at $1000
Proof of date of birth
*
I have provided proof of date of birth with this application
Upload ID with proof of date of birth:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Name
*
First Name
Last Name
Receiving the Elders Gift Card
Once confirmed you are a current member of Yamatji Southern Regional Corporation your Elders Gift Card will be sent out to your postal address you have supplied above.
Continue
Continue
Should be Empty: