REQUEST FOR AN RSL WA ADVOCATE

Personal Information

Do you have a DVA file number? *

YESNO

DVA File Number *

Do you have MyService (DVA online services) connected to your MyGov account? *

YesNo

If other than listed, please specify: *

Given Name(s) *

Last Name *

Did you serve under any other names? *

YESNO

What was the name? *

Email Address *

Do you currently have a fixed abode? *

YESNO

Residential Address *Please include postcode

Do you have a different postal address? *

YESNO

Postal AddressPlease include postcode

Contact Number *

Date of Birth *

Are you an RSLWA member? *

YesNo

Next of Kin / Alternate Contact Information

Name *

Relationship to veteran *

Contact Address *

Telephone number *

ADF Service History

Branch of Service *

ArmyNavy Air ForceCadets

Enlistment Date *Please estimate if actual dates are unknown

Full Time, Reserves, or Both *

Full TimeReservesBoth

Are you still serving? *

YESNO

Have you contacted the on-base Veterans Services Officer (VSO) *

YESNO

Discharge Date

Discharge Reason *

Service Number *

Rank *

Current Unit

Last Unit

Nature of duties *

Have you deployed on warlike and/or non-warlike operations? *

YESNO

Please note that Op Resolute is not deemed warlike or non-warlike service

What operation or operations did you serve as part of? *Please include dates if available, but if you are unsure of exact dates please note that and instead include an estimate.

Have you deployed on an operation or operations but are unsure of their warlike or non-warlike classification? *

YesNo

What operation or operations did you serve as part of? *Please include dates if available, but if you are unsure of exact dates please note that and instead include an estimate.

DVA Claims History

Have you previously claimed with DVA? *

YESNO

Are you seeking assistance with a new liability claim? *

YESNO

Are you seeking assistance with a claim you have already submitted? *

YesNo

What are the details of the previously submitted claim? *Please include: conditions claimed, date of claim lodgement, prior advocate information if you had representation, and any other information you have available.

Are you seeking assistance with re-submitting a previously rejected claim? *

YESNO

Are you seeking assistance with appealing a recent determination? *

YESNO

Are you lodging any claims for a terminal illness? *

YESNO

Please indicate which conditions you are seeking assistance with *

Have these conditions been formally diagnosed by a medical practitioner? *

YESNO

Please note, this does not include psychologists, physiotherapists, occupational therapists, or chiropractors

Medical Information

Local medical practitioner's name *

Address

Contact Number

Do you currently have a copy of your ADF medical and service records? *

YESNO

Are these electronic records? *

YESNO

Would you like to request an electronic copy of your ADF records?

YESNO

Request my ADF Records

Employment

Are you currently employed? *

YESNO

Date ceased work *

Are you currently receiving incapacity payments? *

YESNO

Name of current employer *

How many hours do you work per week? *

Are you still seeking employment ? *

YESNO

Would you like assistance with RSL's Veteran's Employment Program? *

YESNO

Welfare Services

RSL can assist you with emergency financial relief for essentials such as food, rent, utility bills, security bonds, funeral costs, education, clothing, urgent car repairs, transport and referrals to other appropriate services.

Would you like assistance from RSL WA's Welfare Officer ? *

YESNO

Declaration

RSL WA agrees to:

act conscientiously and in good faith, and follow all reasonable instructions to best provide Services for the clients and not allow its own interests to conflict with its duties to the Client;
refer to itself as "advocates or representatives" of the Client in all dealings for the provision of services;
except as may be authorised by the Client, RSL WA shall not in any way incur any liabilities on behalf of the Client or pledge the credit of the Client.

The Client agrees to:

act dutifully and in good faith in its relations with RSL WA;
disclose all relevant medical information pertaining to the Client’s “Claim”;
where appropriate, inform RSL WA within a reasonable time of any problems about being able to meets its obligations under any contract concluded by RSL WA.

By signing this agreement, I hereby declare that;

All of the information I have provided is true and accurate to the best of my knowledge

I have not provided any misleading or false information

Client Signature *

Draw signature|Type signatureClear

Date *

An RSL WA Advocate will contact you at the earliest opportunity.

Once you have submitted this form, you will be automatically directed to the RSL WA website. Please accept this as confirmation that we have received your request.

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