Gifting Application Form

Level of injury*
How was your injury sustained?*
Please comment on how your injury was sustained*
Are you receiving or have you received any compensation or insurance payment?*
- Yes
- No

What type of equipment/home adaptations or funding do you require?*
Value of equipment being purchased:*
What amount is requested from PBF? ($)*
What avenues have you tried to gain funding?*
Please comment on the other avenues you have tried to gain funding.*
How much have you received from the above-mentioned funding? ($)*
If the total value of the equipment/home adaptations or funding exceeds $5,000, please provide details of how the shortfall will be covered.*
Why do you need the equipment/home adaptations or funding?*

Three quotations must be supplied — are these uploaded below?*
- Yes
- No
Valid applications require three quotations for the equipment under consideration, please upload below.
Quotation 1
Drop files here or

Max. file size: 50 MB.
Quotation 2
Drop files here or

Max. file size: 50 MB.
Quotation 3
Drop files here or

Max. file size: 50 MB.
If three quotations cannot be obtained please provide details as to why.*

A letter of support outlining the reasons why the equipment or home adaptations are required, must be supplied from a doctor, physiotherapist, occupational therapist, or allied health professional — is this uploaded below?*
- Yes
- No
A valid Statement of Hardship must accompany all applications. Please upload your statement from your relevant health professional.*
Drop files here or

Max. file size: 50 MB.
Name of health professional*
Occupation*
Health professional's phone number
Health professional's email address

Statement of hardship must be provided as an overview of your assets, income, and the reasons why you are ineligible for other funding schemes. Please note your answers may not exclude you from receiving the funding.
Please answer the following:
1. Do you own your own home?*
- Yes (outright or mortgaged)
- No (rental, government assistance, etc.)
2. Do you have savings?*
- Yes
- No
3. What is the estimated value of your assets? ($)*
4. Are you employed?*
- Yes
- No
Please provide a written statement outlining your statement of hardship the reasons why you are ineligible for other funding schemes, utilising the questions above.*

If your application is successful, a PBF representative would like to be in attendance when the equipment is delivered. Do you agree to a PBF representative attending when the gifted equipment is received?*
- Yes
- No
If your application is successful, do you agree for PBF to use your story and photos for awareness raising of our gifting program via social media posts or other media use?*
- Yes
- No
Do you have any additional information:*
PBF (Australia) Pty Ltd ABN 39 521 178 651 | AFSL 301359. How PBF (Australia) Pty Ltd (PBF) collects, uses, discloses, keeps, and secures your personal information including how to opt out from direct marketing, how to request access to a correction of your personal information or how to complain about a privacy breach and how this is handled by PBF is explained in the PBF privacy policy. For a copy of this policy, call our member services team on 1800 809 780 or go to www.pbf.asn.au/privacy-policy
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Gifting application form