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TAC Taxi Account Application

TAC Account Application

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TAC Travel Account Application Form

The personal information provided within this application and sensitive in nature and is strictly used in accordance with the application processes. All data that is collected, is done so and used in accordance with our privacy policy.

If your application does not proceed, then the information collected in this form will be destroyed in accordance with our privacy policy and or relevant Victorian state or Australian Government regulations.

It’s paramount that you answer each question honestly and the information you provide to us is yours to provide. If it is found that you are using someone else details or the identifiable information you provide found to be forged or fake the matter will be forwarded to the appropriate authorities and your application will be withdrawn.

This application will take between 15 – 45 minutes to complete.

Do you consent to having your data collected and stored?

Yes

No

We are unable to proceed with your application if we are unable to store and collect your personal data.

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Passenger Details

First Name:*

Middle Name(s):

Last Name:*

Address:*

Suburb:*

State:*

Postcode:*

Email Address:*

Landline:

Mobile:*

NDIS Account Number*

NDIS Plan Number*

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Account Type

It’s important that you answer all questions truthfully and with honesty. Failure to do so will result in your application being rejected and your data collected and help being destroyed.

Who is filling out this application?*

The Applicant

Service Coordinator

Other

Please provide more details:*

e.g: Your name, Position, Company your representing etc

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Emergency Contact Details

First Name:*

Last Name:*

Address:*

Suburb:*

State:*

Postcode:*

Email address*

Landline:

Mobile:*

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Eureka Taxis NDIS Application Form

Case Manager / Support Workers Contact Details

It’s important that you answer all the questions truefully and with honesty. Failure to do so will result in your application being rejected and your data destroyed.

Agency / Organization Type:*

Company

Non-For-Profit

Other

Other (Please Specify)*

First Name:*

Middle Name(s):

Last Name:*

Address:*

Suburb:*

State:*

Postcode:*

Business / Company Name:*

ABN Number:*

ACN Number:*

Email Address:*

Landline:*

Mobile:*

Does the applicant have a daily transport limit?*

Yes

No

Unsure

Limit Amount ($)*

Does the applicant have a daily transport limit?*

Yes

No

Unsure

Limit Amount ($)*

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Eureka Taxis NDIS Application Form

Billing / Account Details

It’s important that you answer all the questions truefully and with honesty. Failure to do so will result in your application being rejected and your data destroyed.

First Name:*

Last Name:*

Address:*

Suburb:*

State:*

Postcode:*

Business / Company Name:*

ABN Number:*

ACN Number:*

Email Address:*

Landline:*

Mobile:*

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Application Questionnaire

It’s important that you answer all the questions truthfully and with honesty. Failure to do so will result in your application being rejected and your data destroyed.

Has the applicant had a transport plan cancelled or not renewed with any transport provider in the last 5 years?*

Yes

No

Please provide more information*

Is the participant moving transport providers?*

Yes

No

Current Transport Provider*

Reason for transport transfer*

Do the applicant have any limitation on transportation, such as needing a wheelchair, scooter or any other special needs?*

Yes

No

Please provide more information*

This may include, but not limit past or current physical mobility and or current or past mental health issues

Does the applicant require a seatbelt buckle and or child lock?*

Yes

No

Please provide more information*

This may include, but not limit past or current physical mobility and or current or past mental health issues

Please provide a copy of a medical certificate from a registered general practitioner / specialist *

Do the applicant have any limitation on transportation, such as needing a wheelchair, scooter or any other special needs?*

This may include history of past and current physical mobility and or past and current mental health issues

Does the applicant have regular medical appointments / specialist’s appointments? If so please list them here*

Is there any special requirements or medical conditions that our drivers need to know about?*

Is the service coordinator imposing any travel restrictions *

Yes

No

Please provide (in detail) what restrictions you are imposing *

Is the applicant registering for female only driver transport*

Yes

No

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Level 1
35-37 Peel Street South
Bakery Hill 3350

Head Office

Contact Numbers

1300 18 33 60

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03 4335 0202

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03 4335 0204

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03 4335 0204

Administration

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