Note: More Information - Eastern Health Health... · Email: [email protected] Phone: 1300 361 669 Fax: 03 9879 8703 Location: Suite 18, 45-51, Ringwood Street,

Salary Packaging Card

Card Type(s) Required

Threshold Visa Card M

eal Leisure Visa Card

Do you require N

AB Internet/Telephone Banking?

Yes N

o Are you an existing N

AB custom

er? Yes

No

Cardholder ConsentTo the N

ational Australia Bank Lim

ited (“NA

B”) I am the person nam

ed above as Cardholder:

• [Consent to issue of card] I consent to the issue of a card type selected above (“Card”) in my nam

e. I understand I am authorised to use this Card on behalf of m

y employer

for salary packaging purposes. I acknowledge that any use of the Card w

ill be governed by Conditions of Use w

hich will be provided w

ith the card.

• [My personal inform

ation] I acknowledge that details about N

AB’s treatm

ent of my personal inform

ation, including how I m

ay gain access to that information, are set out

in NA

B’s Privacy Notifi cation, a copy of w

hich will accom

pany the Card (I may also dow

nload this document at nab.com

.au)

• [Authority to disclose to my em

ployer and Salary Sacrifi ce Provider] I authorise NA

B to disclose to my em

ployer and Salary Sacrifi ce Service Provider (Eastern Health)

and authorise my em

ployer and Salary Sacrifi ce Service Provider to seek from N

AB inform

ation relating to my use of the Card (including any inform

ation relating to any transactions I carry out or attem

pt to carry out with the Card) for the purposes of salary sacrifi ce adm

inistration and managem

ent. This authority is given in addition to the m

atters set out in the NA

B Privacy Notifi cation. I understand that if I have any questions or concerns about how

my em

ployer or Salary Sacrifi ce Service Provider uses or discloses inform

ation about me provided to them

by NA

B I should discuss this with m

y employer or Salary Sacrifi ce Service Provider.

Note: The em

ployer named above is the Custom

er who authorises the issue of the Card to the Cardholder and as defi ned in the Conditions of U

se.

Full Nam

e Em

ployee ID

Address

Employee Signature

Date / /

Employer U

se Only

Customer A

uthorityThe custom

er hereby requests issue of a Card/s to the Cardholder named above pursuant to the Custom

er’s NA

B Business Card (Salary Packaging) Facility Terms and

Conditions (“Facility”) agreed between N

AB and the Custom

er. The Cardholder’s signature is verifi ed and Cardholder Request approved. Signed on behalf of the Customer.

Authorised Signature/s D

ate / /

Employee Signature

Date / /

Public Authorities and Incorporated Bodies as defi ned under the FTR Act (these include incorporated associations and proprietary companies that have traded for a continuous

period of two years, or m

aintained an account with a fi nancial institution for a continuous period of tw

o years) may nom

inate a Verifying Offi cer under the FTR Act.

Certifi cate of IdentityI, the undersigned, in the capacity of Verifying O

ffi cer for Eastern Health, certify that the person detailed below

, has been identifi ed, and is authorised to open a NAB Salary

Packaging account.

Sight the required documentation (identifi cation list is located on the Eastern H

ealth salary packaging website under form

s and documents) and com

plete the following:

Identifi cation Docum

ent Details

Docum

ent 1D

ocument 2

Verifi ed From O

riginal Certifi ed Copy*

Original

Certifi ed Copy*

Docum

ent Type (eg: Australian Passport)

Issued By (eg: Local Governm

ent)

Issued Date

Expiry Date

Docum

ent Num

ber

Verifying Offi cer D

etailsI confi rm

that I have sighted the original or a certifi ed copy of the original documents and verify that the above is true and correct. A

ny wilful breach of identifi cation

obligations are made punishable under the A

ML Act 2006. I confi rm

I have supplied the above individual with a N

AB privacy brochure.

Identifi cation verifi ed by:

Verifying Offi cer N

ame

Position

Authorised Signature/sD

ate / /

Application Form

Salary packaging is a government approved way of structuring your income that allows you to pay for everyday goods and services from your salary before it’s taxed.

What is salary packaging?

Salary PackagingTake home more with a great career

More InformationFor more information about salary packaging, contact the Eastern Health Salary Packaging Unit Monday-Friday between 9am-4pm.

Email: [email protected]

Phone: 1300 361 669

Fax: 03 9879 8703

Location: Suite 18, 45-51, Ringwood Street, Ringwood VIC 3134

Post: PO BOX 359, Ringwood VIC 3134

Website: https://easternhealth.seqoya.com.au

Give your salary a health check

and pay less tax

Ringwood Bypass

Creek St

Reynolds Ave

Nelson St

Bourke St

Bond St

Ringwood St

Ringwood W

arrandyte Rd



Threshold Visa Card M

eal Leisure Visa Card

Do you require N

AB Internet/Telephone Banking?

Yes N

o Are you an existing N

AB custom

er? Yes

No

Cardholder ConsentTo the N

ational Australia Bank Lim

ited (“NA

B”) I am the person nam

ed above as Cardholder:

• [Consent to issue of card] I consent to the issue of a card type selected above (“Card”) in my nam

e. I understand I am authorised to use this Card on behalf of m

y employer

for salary packaging purposes. I acknowledge that any use of the Card w

ill be governed by Conditions of Use w

hich will be provided w

ith the card.

• [My personal inform

ation] I acknowledge that details about N

AB’s treatm

ent of my personal inform

ation, including how I m

ay gain access to that information, are set out

in NA

B’s Privacy Notifi cation, a copy of w

hich will accom

pany the Card (I may also dow

nload this document at nab.com

.au)

• [Authority to disclose to my em

ployer and Salary Sacrifi ce Provider] I authorise NA

B to disclose to my em

ployer and Salary Sacrifi ce Service Provider (Eastern Health)

and authorise my em

ployer and Salary Sacrifi ce Service Provider to seek from N

AB inform

ation relating to my use of the Card (including any inform

ation relating to any transactions I carry out or attem

pt to carry out with the Card) for the purposes of salary sacrifi ce adm

inistration and managem

ent. This authority is given in addition to the m

atters set out in the NA

B Privacy Notifi cation. I understand that if I have any questions or concerns about how

my em

ployer or Salary Sacrifi ce Service Provider uses or discloses inform

ation about me provided to them

by NA

B I should discuss this with m

y employer or Salary Sacrifi ce Service Provider.

Note: The em

ployer named above is the Custom

er who authorises the issue of the Card to the Cardholder and as defi ned in the Conditions of U

se.

Full Nam

e Em

ployee ID

Address

Employee Signature

Date / /

Employer U

se Only

Customer A

uthorityThe custom

er hereby requests issue of a Card/s to the Cardholder named above pursuant to the Custom

er’s NA

B Business Card (Salary Packaging) Facility Terms and

Conditions (“Facility”) agreed between N

AB and the Custom

er. The Cardholder’s signature is verifi ed and Cardholder Request approved. Signed on behalf of the Customer.

Authorised Signature/s D

ate / /

Employee Signature

Date / /

Public Authorities and Incorporated Bodies as defi ned under the FTR Act (these include incorporated associations and proprietary companies that have traded for a continuous

period of two years, or m

aintained an account with a fi nancial institution for a continuous period of tw

o years) may nom

inate a Verifying Offi cer under the FTR Act.

Certifi cate of IdentityI, the undersigned, in the capacity of Verifying O

ffi cer for Eastern Health, certify that the person detailed below

, has been identifi ed, and is authorised to open a NAB Salary

Packaging account.

Sight the required documentation (identifi cation list is located on the Eastern H

ealth salary packaging website under form

s and documents) and com

plete the following:

Identifi cation Docum

ent Details

Docum

ent 1D

ocument 2

Verifi ed From O

riginal Certifi ed Copy*

Original

Certifi ed Copy*

Docum

ent Type (eg: Australian Passport)

Issued By (eg: Local Governm

ent)

Issued Date

Expiry Date

Docum

ent Num

ber

Verifying Offi cer D

etailsI confi rm

that I have sighted the original or a certifi ed copy of the original documents and verify that the above is true and correct. A

ny wilful breach of identifi cation

obligations are made punishable under the A

ML Act 2006. I confi rm

I have supplied the above individual with a N

AB privacy brochure.

Identifi cation verifi ed by:

Verifying Offi cer N

ame

Position

Authorised Signature/sD

ate / /

Application Form






Phone: 1300 361 669

Fax: 03 9879 8703





and pay less tax

Ringwood Bypass

Creek St

Reynolds Ave

Nelson St

Bourke St

Bond St

Ringwood St

Ringwood W

arrandyte Rd

App

licat

ion

Form

1. P

erso

nal D

etai

ls (P

leas

e pr

int i

n bl

ock

lett

ers)

Empl

oyee

Num

ber

Title

(Mr,

Ms,

etc)

Gen

der

M

ale

F

emal

e

Empl

oym

ent S

tatu

s

Ful

l-Tim

e

Par

t-Tim

e

Cas

ual

Full

Nam

eD

ate

of B

irth

/

/

Addr

ess

Subu

rbPo

stco

de

Hom

e Ph

one

Busi

ness

Pho

ne

Mob

ile P

hone

Emai

l

2. P

acka

ge It

ems (

Plea

se p

rint i

n bl

ock

lett

ers)

Pack

age

Item

BSB

Acc

ount

No

Acc

ount

Nam

e/Pa

yee

Am

ount

EG. C

redi

t Car

d73

3 - 6

2401

23Jo

hn S

mith

$349

.80

- - -

Thre

shol

d Ca

rd -

refe

r to

card

ap

plic

atio

n fo

rm o

verle

af

Mea

l Lei

sure

Car

d - r

efer

to c

ard

appl

icat

ion

form

ove

rleaf

Supe

rann

uati

onM

embe

rshi

p N

o.Fu

nd N

ame

Fund

Add

ress

Nov

ated

Lea

sing

- I a

m in

tere

sted

in fi

ndin

g ou

t mor

e ab

out N

ovat

ed L

easi

ng a

nd w

ould

like

to b

e co

ntac

ted

by a

Sm

artle

asin

g co

nsul

tant

.

For f

urth

er in

form

atio

n re

fer t

o th

e Ea

ster

n H

ealth

Sal

ary

Pack

agin

g Em

ploy

ee In

form

atio

n G

uide

whi

ch is

ava

ilabl

e on

Eas

tern

Hea

lth’s

web

site

at h

ttp:

//w

ww

.seq

oya.

com

.au/

east

ernh

ealth

/Hom

e.as

px.

Prio

r to

star

ting

sala

ry p

acka

ging

we

enco

urag

e al

l em

ploy

ees

to s

eek

inde

pend

ent fi

nan

cial

adv

ice

- it i

s em

ploy

ees’

resp

onsi

bilit

y to

do

this

.

3. C

osts

I und

erst

and

that

any

app

licab

le a

dmin

istr

atio

n co

sts

will

be

dedu

cted

from

my

pre-

tax

sala

ry.

4. D

ocum

enta

ry E

vide

nce

To p

rove

pay

men

ts a

re b

eing

mad

e in

to le

gitim

ate

bene

fi t it

ems,

plea

se p

rovi

de c

opie

s of

rece

nt s

tate

men

ts fo

r ite

ms

bein

g pa

ckag

ed.

Bene

fi tEv

iden

ceSu

pplie

d

Mor

tgag

eSc

hedu

le o

f Rep

aym

ents

from

you

r ban

k st

atem

ent

Pers

onal

Loa

nSc

hedu

le o

f Rep

aym

ents

from

you

r ban

k st

atem

ent

Rent

Rent

al A

gree

men

t fro

m re

al e

stat

e ag

ent/

land

lord

Cred

it C

ard

Full

stat

emen

t of t

otal

cre

dits

mad

e fo

r the

mon

th

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rann

uati

onM

embe

r Sta

tem

ent

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ipts

Mus

t be

in y

our n

ame,

you

r spo

use'

s na

me,

or j

oint

nam

es

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er n

on-F

BTO

rigin

al in

voic

e an

d ba

nk s

tate

men

t

5. A

ckno

wle

dgem

ent a

nd C

onse

ntI w

ish

to a

pply

to p

artic

ipat

e in

the

East

ern

Hea

lth S

alar

y Pa

ckag

ing

prog

ram

. I h

ave

read

, und

erst

ood

and

acce

pted

the

Term

s an

d Co

nditi

ons

of S

alar

y Pa

ckag

ing

at E

aste

rn H

ealth

, whi

ch is

ava

ilabl

e on

the

East

ern

Hea

lth s

alar

y pa

ckag

ing

web

site

und

er ‘E

mpl

oyee

Ben

efi t

s’ –

‘Sal

ary

Pack

agin

g’.

Empl

oyee

Sig

natu

reD

ate

/

/

Sala

ry P

acka

ging

East

ern

Hea

lth

Sala

ry P

acka

ging

Uni

t Su

ite 1

8, 4

5-51

, Rin

gwoo

d St

reet

, Rin

gwoo

d V

IC 3

134

Post

PO

BO

X 35

9, R

ingw

ood

VIC

313

4 p

1300

361

669

f 0

3 98

79 8

703

e s

alar

ypac

kagi

ng@

east

ernh

ealth

.org

.au

Once you enter into a salary packaging arrangement with Eastern Health we calculate the amount to set aside from your pay based on your chosen benefits. This untaxed money is then returned to you via your nominated bank account each fortnight. It’s that simple!

Why salary package?By effectively salary packaging, you can increase your take home salary by thousands of dollars each year. Just take a look at the benefits:

Not Packaging Packaging

Gross Salary $2,640.00 Gross Salary $2,640.00

PAYG Tax - $574.00 Salary Package -$449.80

Take Home Pay $2,066.00 New Gross Salary $2,190.20

By salary packaging you can increase your disposable income

by $150.00 per fortnight or $3,900.00 per year. That’s

a significant difference!

PAYG Tax -$420.00

Take Home Pay $1,770.20

Tax Benefit - Salary Packaging Amount +$449.80

Disposable Income $2,220.00 * Example calculation has been based on fortnight deduction $349.80 threshold + $100.00 Meal Accommodation benefits

Prior to starting salary packaging we encourage all employees to seek independent financial advice - it is employees’ responsibility to do this.

How much can I salary package?Full-time and part-time employees can salary package their regular base salary (penalties or overtime cannot be packaged). Casual employees can salary package up to 80% of their income.

What can I package? How much does it cost?

Auth

orise

d by

Eas

tern

Hea

lth: E

H12

10 S

P006

How does salary packaging work?

You can salary package a variety of expenses from your pre-tax salary up to a limit of $9,095 each Fringe Benefits Tax (FBT) year (1 April-31 March). Some of the benefits include: Eastern Health Threshold Visa Card

(groceries, fuel, clothes, bills)

Home Mortgage Repayments Personal Loan Payments Home Rental Payments Credit Card Payments School Fees & Child Care Expenses Health Insurance Payments

You can also salary package other benefits over the $9,095 limit, including: Eastern Health Meal Leisure Visa Card

(Dining out, Holiday Accommodation, venue hire)

Meal Entertainment Holiday Expenses & Venue Hire Superannuation Work Related Equipment (laptops, iPads)There are costs involved in Eastern Health administering all your salary packaging arrangements. The cost amount will depend on

the benefit packaged and it is paid from your pre-tax salary. For more information on these costs, refer to Eastern Health’s Salary Packaging Employee Information Guide.

What is meal entertainment?Whether you eat out once-a-week or every night, dine out with your friends, colleagues and family using your Meal Leisure Visa Card.

You’ll have instant access to your pre-tax dollars to spend on food and drink at restaurants, cafés, while on holiday – even catering for a party.

What is a holiday expense?Enjoy tax-free holiday expenses when travelling in Australia or overseas. It includes holiday packages booked and paid through a travel agent and accommodation expenses for stays at hotels, motels, resorts, caravan parks and cabins, as well as holiday homes and cruises.

What is venue hire?Getting married? Having a party? Use your pre-tax dollars to pay venue hire costs for private functions. Now that expensive reception centre, function room or garden marquee is well within your budget.

What is a novated lease?Looking to buy a new car? Consider a novated lease - it’s the most tax effective way to finance your next vehicle! Enjoy great tax savings on your lease payments, fuel and running expenses like insurance, rego and maintenance. To find out more contact Smartleasing on 1300 187 590.

App

licat

ion

Form

1. P

erso

nal D

etai

ls (P

leas

e pr

int i

n bl

ock

lett

ers)

Empl

oyee

Num

ber

Title

(Mr,

Ms,

etc)

Gen

der

M

ale

F

emal

e

Empl

oym

ent S

tatu

s

Ful

l-Tim

e

Par

t-Tim

e

Cas

ual

Full

Nam

eD

ate

of B

irth

/

/

Addr

ess

Subu

rbPo

stco

de

Hom

e Ph

one

Busi

ness

Pho

ne

Mob

ile P

hone

Emai

l

2. P

acka

ge It

ems (

Plea

se p

rint i

n bl

ock

lett

ers)

Pack

age

Item

BSB

Acc

ount

No

Acc

ount

Nam

e/Pa

yee

Am

ount

EG. C

redi

t Car

d73

3 - 6

2401

23Jo

hn S

mith

$349

.80

- - -

Thre

shol

d Ca

rd -

refe

r to

card

ap

plic

atio

n fo

rm o

verle

af

Mea

l Lei

sure

Car

d - r

efer

to c

ard

appl

icat

ion

form

ove

rleaf

Supe

rann

uati

onM

embe

rshi

p N

o.Fu

nd N

ame

Fund

Add

ress

Nov

ated

Lea

sing

- I a

m in

tere

sted

in fi

ndin

g ou

t mor

e ab

out N

ovat

ed L

easi

ng a

nd w

ould

like

to b

e co

ntac

ted

by a

Sm

artle

asin

g co

nsul

tant

.

For f

urth

er in

form

atio

n re

fer t

o th

e Ea

ster

n H

ealth

Sal

ary

Pack

agin

g Em

ploy

ee In

form

atio

n G

uide

whi

ch is

ava

ilabl

e on

Eas

tern

Hea

lth’s

web

site

at h

ttp:

//w

ww

.seq

oya.

com

.au/

east

ernh

ealth

/Hom

e.as

px.

Prio

r to

star

ting

sala

ry p

acka

ging

we

enco

urag

e al

l em

ploy

ees

to s

eek

inde

pend

ent fi

nan

cial

adv

ice

- it i

s em

ploy

ees’

resp

onsi

bilit

y to

do

this

.

3. C

osts

I und

erst

and

that

any

app

licab

le a

dmin

istr

atio

n co

sts

will

be

dedu

cted

from

my

pre-

tax

sala

ry.

4. D

ocum

enta

ry E

vide

nce

To p

rove

pay

men

ts a

re b

eing

mad

e in

to le

gitim

ate

bene

fi t it

ems,

plea

se p

rovi

de c

opie

s of

rece

nt s

tate

men

ts fo

r ite

ms

bein

g pa

ckag

ed.

Bene

fi tEv

iden

ceSu

pplie

d

Mor

tgag

eSc

hedu

le o

f Rep

aym

ents

from

you

r ban

k st

atem

ent

Pers

onal

Loa

nSc

hedu

le o

f Rep

aym

ents

from

you

r ban

k st

atem

ent

Rent

Rent

al A

gree

men

t fro

m re

al e

stat

e ag

ent/

land

lord

Cred

it C

ard

Full

stat

emen

t of t

otal

cre

dits

mad

e fo

r the

mon

th

Supe

rann

uati

onM

embe

r Sta

tem

ent

Rece

ipts

Mus

t be

in y

our n

ame,

you

r spo

use'

s na

me,

or j

oint

nam

es

Oth

er n

on-F

BTO

rigin

al in

voic

e an

d ba

nk s

tate

men

t

5. A

ckno

wle

dgem

ent a

nd C

onse

ntI w

ish

to a

pply

to p

artic

ipat

e in

the

East

ern

Hea

lth S

alar

y Pa

ckag

ing

prog

ram

. I h

ave

read

, und

erst

ood

and

acce

pted

the

Term

s an

d Co

nditi

ons

of S

alar

y Pa

ckag

ing

at E

aste

rn H

ealth

, whi

ch is

ava

ilabl

e on

the

East

ern

Hea

lth s

alar

y pa

ckag

ing

web

site

und

er ‘E

mpl

oyee

Ben

efi t

s’ –

‘Sal

ary

Pack

agin

g’.

Empl

oyee

Sig

natu

reD

ate

/

/

Sala

ry P

acka

ging

East

ern

Hea

lth

Sala

ry P

acka

ging

Uni

t Su

ite 1

8, 4

5-51

, Rin

gwoo

d St

reet

, Rin

gwoo

d V

IC 3

134

Post

PO

BO

X 35

9, R

ingw

ood

VIC

313

4 p

1300

361

669

f 0

3 98

79 8

703

e s

alar

ypac

kagi

ng@

east

ernh

ealth

.org

.au










PAYG Tax -$420.00







Auth

orise

d by

Eas

tern

Hea

lth: E

H12

10 S

P006







Meal Entertainment Holiday Expenses & Venue Hire Superannuation Work Related Equipment (laptops, iPads) Novated Leasing

There are costs involved in Eastern Health administering all your salary packaging arrangements. The cost amount will depend on the benefit packaged and it is paid from your pre-tax salary. For more information on these costs, refer to Eastern Health’s Salary Packaging Employee Information Guide.






App

licat

ion

Form

1. P

erso

nal D

etai

ls (P

leas

e pr

int i

n bl

ock

lett

ers)

Empl

oyee

Num

ber

Title

(Mr,

Ms,

etc)

Gen

der

M

ale

F

emal

e

Empl

oym

ent S

tatu

s

Ful

l-Tim

e

Par

t-Tim

e

Cas

ual

Full

Nam

eD

ate

of B

irth

/

/

Addr

ess

Subu

rbPo

stco

de

Hom

e Ph

one

Busi

ness

Pho

ne

Mob

ile P

hone

Emai

l

2. P

acka

ge It

ems (

Plea

se p

rint i

n bl

ock

lett

ers)

Pack

age

Item

BSB

Acc

ount

No

Acc

ount

Nam

e/Pa

yee

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PAYG Tax -$420.00







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H12

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Meal Entertainment Holiday Expenses & Venue Hire Superannuation Work Related Equipment (laptops, iPads) Novated Leasing

There are costs involved in Eastern Health administering all your salary packaging arrangements. The cost amount will depend on the benefit packaged and it is paid from your pre-tax salary. For more information on these costs, refer to Eastern Health’s Salary Packaging Employee Information Guide.











Phone: 1300 361 669

Fax: 03 9879 8703





and pay less tax

Ringwood Bypass

Creek St

Eastland Shopping Centre

Reynolds Ave

Nelson St

Bourke St

Bond St

Ringwood St

Ringwood W

arrandyte Rd

Application Form

1. Personal Details (Please print in block letters)

Employee Number Title (Mr, Ms, etc) Gender Male Female

Employment Status Full-Time Part-Time Casual

Full Name Date of Birth / /

Address

Suburb Postcode

Home Phone Business Phone

Mobile Phone Email

2. Package Items (Please print in block letters)

Package Item BSB Account No Account Name/Payee Amount

EG. Credit Card 733 - 624 0123 John Smith $349.80

-

-

-

Threshold Card - refer to card application form overleaf

Meal Leisure Card - refer to card application form overleaf

Superannuation Membership No. Fund Name

Fund Address

Novated Leasing - I am interested in finding out more about Novated Leasing and would like to be contacted by a Smartleasing consultant.

For further information refer to the Eastern Health Salary Packaging Employee Information Guide which is available on Eastern Health’s website at http://www.seqoya.com.au/easternhealth/Home.aspx.


3. Costs I understand that any applicable administration costs will be deducted from my pre-tax salary.

4. Documentary Evidence

To prove payments are being made into legitimate benefit items, please provide copies of recent statements for items being packaged.

Benefit Evidence Supplied

Mortgage Schedule of Repayments from your bank statement

Personal Loan Schedule of Repayments from your bank statement

Rent Rental Agreement from real estate agent/landlord

Credit Card Full statement of total credits made for the month

Superannuation Member Statement

Receipts Must be in your name, your spouse's name, or joint names

Other non-FBT Original invoice and bank statement

5. Acknowledgement and ConsentI wish to apply to participate in the Eastern Health Salary Packaging program. I have read, understood and accepted the Terms and Conditions of Salary Packaging at Eastern Health, which is available on the Eastern Health salary packaging website under ‘Employee Benefits’ – ‘Salary Packaging’.

Employee Signature Date / /

Salary Packaging

Eastern Health Salary Packaging Unit Suite 18, 45-51, Ringwood Street, Ringwood VIC 3134 Post PO BOX 359, Ringwood VIC 3134 p 1300 361 669 f 03 9879 8703 e [email protected]



Threshold Visa Card Meal Leisure Visa Card

Do you require NAB Internet/Telephone Banking? Yes No Are you an existing NAB customer? Yes No

Cardholder ConsentTo the National Australia Bank Limited (“NAB”) I am the person named above as Cardholder:

• [Consent to issue of card] I consent to the issue of a card type selected above (“Card”) in my name. I understand I am authorised to use this Card on behalf of my employer for salary packaging purposes. I acknowledge that any use of the Card will be governed by Conditions of Use which will be provided with the card.

• [My personal information] I acknowledge that details about NAB’s treatment of my personal information, including how I may gain access to that information, are set out in NAB’s Privacy Notification, a copy of which will accompany the Card (I may also download this document at nab.com.au)

• [Authority to disclose to my employer and Salary Sacrifice Provider] I authorise NAB to disclose to my employer and Salary Sacrifice Service Provider (Eastern Health) and authorise my employer and Salary Sacrifice Service Provider to seek from NAB information relating to my use of the Card (including any information relating to any transactions I carry out or attempt to carry out with the Card) for the purposes of salary sacrifice administration and management. This authority is given in addition to the matters set out in the NAB Privacy Notification. I understand that if I have any questions or concerns about how my employer or Salary Sacrifice Service Provider uses or discloses information about me provided to them by NAB I should discuss this with my employer or Salary Sacrifice Service Provider.

Note: The employer named above is the Customer who authorises the issue of the Card to the Cardholder and as defined in the Conditions of Use.

Full Name Employee ID

Address DOB / /


Employer Use OnlyCustomer Authority The customer hereby requests issue of a Card/s to the Cardholder named above pursuant to the Customer’s NAB Business Card (Salary Packaging) Facility Terms and Conditions (“Facility”) agreed between NAB and the Customer. The Cardholder’s signature is verified and Cardholder Request approved. Signed on behalf of the Customer.

Authorised Signature/s Date / /


Public Authorities and Incorporated Bodies as defined under the FTR Act (these include incorporated associations and proprietary companies that have traded for a continuous period of two years, or maintained an account with a financial institution for a continuous period of two years) may nominate a Verifying Officer under the FTR Act.

Certificate of IdentityI, the undersigned, in the capacity of Verifying Officer for Eastern Health, certify that the person detailed below, has been identified, and is authorised to open a NAB Salary Packaging account.

Sight the required documentation (identification list is located on the Eastern Health salary packaging website under forms and documents) and complete the following:

Identification Document Details Document 1 Document 2

Verified From Original Certified Copy* Original Certified Copy*

Document Type (eg: Australian Passport)

Issued By (eg: Local Government)

Issued Date

Expiry Date

Document Number

Verifying Officer DetailsI confirm that I have sighted the original or a certified copy of the original documents and verify that the above is true and correct. Any wilful breach of identification obligations are made punishable under the AML Act 2006. I confirm I have supplied the above individual with a NAB privacy brochure.

Identification verified by:

Verifying Officer Name Position

Authorised Signature/s Date / /

Application Form

Documents

Note: More Information - Eastern Health Health... · Email: [email protected] Phone: 1300 361 669 Fax: 03 9879 8703 Location: Suite 18, 45-51, Ringwood Street,