Form Submission is restrictedForm is successfully submitted. Thank you!Authority to Act as an Advocatepage 1page 2Page 3Page 4Name*Date of birth*Email*Address*Home PhoneMobile Phone*Work Phone Full name*Relationship to youPostal Address*Email*Home PhoneMobile Phone*Work Phone -I authorise the provider to act on the instructions of my nominated person. -I understand that provider is not responsible for any actions of my nominated person using this authority. -I understand that this authority comes into effect from the date above or from when form is received whichever is the later. -I understand that I am giving my nominated person authority to access my information by telephone, email and letter -I understand I can write to or call the provider at any time to cancel this authority, and the provider will only cancel this authority if I ask them to in this way. Cancellation will not be effective until received by the provider. Signature*Date* SubmitPowered by ARForms (Unlicensed)