Section A – Applicant details (Customer)
First name *
Last name *
Email address *
Mobile number *
Street address *
Suburb *
Postcode *
Do you have access to the internet and a computer?
Yes, I have access to both
I have access to a computer
I have access to the internet
I don’t have access to either
Section B – Applicant details (Representative, family member or carer)
Your first name
Your last name
Your email address
Your mobile number
Customer details
Customer first name
Customer last name
Relationship to customer
Select
Family member
Carer
Friend
Other
Customer address
Customer suburb
Customer postcode
Do you have access to the internet and a computer?
Yes, I have access to both
I have access to a computer
I have access to the internet
I don’t have access to either
What interests you about becoming a Customer Representative?
Please describe any skills, experience or interests that would help you contribute as a Customer Representative
Would you be interested in joining the Australian Unity Home Health Consumer Panel?
As a panel member, you'd be invited to provide quick, ad hoc feedback throughout the year. This may include reviewing new marketing brochures, proposed process changes, website designs and other improvements we're exploring.
Yes
No
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