NILS Application

Your Emergency Contact
Provide the name of your emergency contact*

First NameLast Name
What is their relationship to you?*

Partner / spouseParentChildSiblingRelativeFriendCarerNeighbourOther
Provide their phone number*
Please enter a valid phone number.
Provide their email address
example@example.com

Centrelink Confirmation eServices (CCeS) Authority

If you would like us to download your Centrelink Statement for you, please carefully read and complete the following section.
- Services Australia will disclose personal information to Toukley Neighbourhood Centre including your name, payment type, payment status, one off payment, income, assets, deductions, shared care arrangements and Youth Allowance Independent Rate to confirm your eligibility for relevant NILS service.
- This consent, once given, remains valid while you are a customer of Toukley Neighbourhood Centre unless you withdraw it by contacting Toukley Neighbourhood Centre or Services Australia.
- If you withdraw your consent or do not alternatively provide proof of your circumstances/details you may not be eligible for the NILS service provided by Toukley Neighbourhood Centre.
  If you have any questions, please contact us on 4396 1555 before completing the following authorisation.
- Alternatively, you can get proof of your circumstances/details from the department yourself and provide it to Toukley Neighbourhood Centre so that your eligibility for relevant NILS service can be determined.
Do you authorise Toukley Neighbourhood Centre No Interest Loans Scheme Inc. to use Centrelink Confirmation eServices to perform a Centrelink enquiry of your customer details in order to enable the business to determine if you qualify for a NILS service.*

YesNo
Please provide your CRN
Signature*

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No Interest Loan Application Form