CD01 - Beach Wheelchair Loan Application Applicant Details Name*This field is required. * Required Field. Address*This field is required. * Required Field. Telephone Number*This field is required. * Required Field. Drivers Licence Number*This field is required. * Required Field. Email Address*This field is required. * Required Field.* Please enter a valid email address. Loan Details Date of Collection Time of Collection Guidelines/Terms and Conditions Please read the Guidelines for Beach Wheelchair Use and the Terms and Conditions of Loan Agreement. I have read the Guidelines for Beach Wheelchair Use? YesNo I have read the Terms and Conditions of Loan Agreement? YesNo Declaration I agree to use the Beach Wheelchair in accordance with the Guidelines for Use and the Loan Agreement? YesNo Current Condition of the Beach Wheelchair I have checked the condition of the wheelchair and found it to be: Select an Option In good condition and ready to use Requires servicing but is still usable Supporting Documentation - If there is any damage or issues to the Beach Wheelchair, please upload a photo/s Max File Size: 10.00 MB Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx I have agreed to submit this application by electronic means. I can confirm that the information given in this application is true, complete and accurate. By checking this box and typing my name below, I am electronically signing my application.*This field is required. Please tick here Signature*This field is required. * Required Field. The City of Greater Geraldton collects the personal information you provide in relation to the Beach Wheelchair Loan Application form so we can deliver the service, process your request, and meet our legal obligations under the Local Government Act 1995 and any other related legislation. Your information may be shared with government agencies, contractors, or others where authorised by law or with your consent. Where required by law, your personal information will be made publicly available, e.g. public registers. The City manages personal information in accordance with relevant privacy legislation and takes reasonable steps to protect it from unauthorised access or disclosure. You may request access to, or correction of, your personal information by contacting the City at privacy@cgg.wa.gov.au. Type the code from the image: The code you entered is not valid. Get Audio CodeType the code from the image Was this page helpful? How can we improve this page? Email Address*This field is required. * Required Field.* Please enter a valid Email Address Type the code from the image: Do not fill this textbox.