Apply for help 1. Applicant DetailsGiven name *Surname *Phone number *Email *Date of birthGenderMaleFemaleOtherCountry of birth AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweDo you identify asAboriginalTorres Straight IslanderNeither2. Period of ServiceFrom DateTo DateArea of Service *Area of ServiceNavyArmyAir ForceImpact of Service *PhysicalIllnessMental HealthOtherIf Other, please provide detailsTransition Seminar Attended *YesNoRank Class *ORNCOSNCOOFFR3. Deployment/sNumber of DeploymentsNoneOneTwoThreeFour or moreLast unit served inDVA File NumberDVA Liability Accepted *YesNoDVA Health Card *WhiteGoldGold with TPIHave you received a lump sum payment? *YesNoAre you currently employed? *YesNoDetails of current and/or planned future DVA applications4. Family DetailsSpouse/Partner NameFull Address (if different to service member)Contact NumberNumber of Children/DependentsNumber of Children/DependentsNo Children1234567891011121314155. Advocate/Support ServiceContact to assist on your behalf.Name of ContactOrganisation Name or UnitContact NumberContact Email6. Request for AssistanceHow can Bravery Trust assist you?We can call to discuss your request for assistance, if you prefer, please leave this area empty.7. Previous AssistanceHave you previously applied for assistance from us or any other trust/organisation? *YesNoHow did you hear about Bravery Trust? *DVAOpen ArmsBravery Trust WebsiteRSLWord of MouthTransition SeminarSocial MediaOtherTick all that are appropriate.If Other, please provide details8. Privacy/Confidentiality Disclaimer and SignatureBy submitting this form to Bravery Trust I certify that my answers are true and complete to the best of my knowledge I authorise Bravery Trust to act on my behalf in any dealings as required with Third parties/Agencies. These will be discussed and confirmed with Bravery Trust as part of my application I acknowledge Bravery Trust is entitled to make any reasonable enquiry to ensure the appropriate use of financial assistance I acknowledge that this permission will remain in place with this application until written advice is received withdrawing permission I understand that any false or misleading information in my application may result in withdrawal of assistance and/or recovery of monies paid I give permission for Bravery Trust to contact me to provide feedback on my application Do you Agree to the terms? *YesFull Name *Date *Request for DocumentsPlease send all required documents via email to email@example.com along with your name in the subject line. Evidence of illness/ injury due to service (DVA or medical report) Served in the Defence Certificate of Service or DVA acceptance Evidence of financial hardship (bank statements) The bills you wish us to consider If you do not currently have access to all the required documents, Bravery Trust will contact you at a later date to supply. Submit ApplicationSave as DraftPlease do not fill in this field.