Client Application

The form below is for use by CarPal clients (or their friends or family members) to provide personal details of the client necessary to enroll them with CarPal.

Next Step:

After you complete the form below and click on the “Submit” button, you will receive an email (at the email address you provide for further CarPal information) that describes what happens next. You may need to check your Spam or Junk Mail folders to see it.

 CarPal Client Application

Email for further CarPal information (Client’s, Friend’s or Family Member’s):

Client’s First Name:

Client’s Last Name:

Client – Street Address:

Client – Suburb:

Client – Postcode:

Client Landline and/or Mobile numbers:

Client’s use of Messagebank:

On mobile onlyOn landline onlyOn BOTH Mbl & LandlineDoes NOT Use Messagebank

Client – DOB:

Pension-DVA-Health Care Card No:

Walking Aid used? What type?

Client has difficulty seeing car colour/car number plates?: (SELECT)

NOYES

Own Mobility Parking Scheme Permit: (SELECT)

NOYESApplication pending

Acceptable Vehicle Type for Client access: (SELECT)

ANY TypeNo SUV

Acceptable Driver Gender: (SELECT)

MALE ONLY

FEMALE ONLY

MALE or FEMALE

NO RIDE OFFER NOTICE – if not 24 hours:

Client – Next of Kin:

Next of Kin Phone No:

Friend/Family Member’s Name (if applying on behalf of Client):

Mbl or Phone No – Friend/Family (if applying on behalf of Client):

Client’s Preferred way to receive invoices: (SELECT)

Australia PostEmail

Email address for invoicing. (Leave BLANK if it’s the same email address given at the top of this form OR if Australia Post was selected):

Any other information or comment:

List Selection:

OnlineFace-to-face

For Client Applications submitted through our website, please select “Online” under List Selection before clicking on “Submit”.

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