Provider Application Form - Care Connect

Your details

Contact person full name*

Your position / job title*

Your email*

Contact phone number*

Supplier details

Company Name*

Supplier ABN**

You can lookup your ABN here.

Street address*

Suburb*

Postcode*

State*

Authorised signatory full name*

An authorised signatory is a person allowed to act on behalf of your business. If more than one person, please use a comma to separate names.

Authorised signatory email address*

Witness full name*

A witness is anybody that knows the Authorised Signatory, personally or professionally.

Witness email address*

Do you have any employees or sub-contractors?*

Service Details

Compliance & documentation

Based on the services selected above, we require some documentation to verify your eligibility as a Partnered Provider. Please upload copies of the following before proceeding.

Upload your documentation*

Drop files here or

Accepted file types: jpeg, jpg, pdf, png, xlsx, xls, doc, docx, Max. file size: 64 MB.

Languages, other than English, that are spoken by care staff

Suburbs or Local Government Areas where you provide your services

Minimum shift length*

eg. 1 hour or 2 hours

Travel rates*

Do you charge a fee when accompanying a client? (if applicable) eg. $1 per km travelled with a client in the car

Cancellation policy and associated costs*

eg. 24 hours

GST*

Do your services attract GST? (Yes or No)

Further information

Programs

Support

Services

About

Start your provider application

Your details

Supplier details

Service Details

Compliance & documentation