Card Application Form | NT Seniors Card

Your details

Title*

Mr
Mrs
Ms
Miss

First name*

Middle initial

Last name*

Date of birth*

Gender*

Male
Female
Other

Country of birth*

Residential address*

Suburb*

Postcode*

Postal address

Same as residential address

Postal address*

Suburb*

Postcode*

Telephone*

Email

For statistical purposes, please indicate:

I am

Working
Not working

I am

On a Pension or Government Allowance
Self Funded Retiree

Do you identify as Aboriginal or Torres Strait Islander?

Yes
No

How long have you lived in the Territory?

Years lived in the Territory

Years

Declaration

To be eligible for a Northern Territory Seniors Card you must be a permanent resident of the Northern Territory and over the age of 60 years old.

By clicking the submit button below this declaration, you confirm that you meet the eligibility criteria.

Confirm eligible age*

I am 60 years of age or older

Confirm permanent NT resident*

I am a permanent resident of the Northern Territory

Confirm circumstance changes*

I agree to advise Seniors Card without delay if I change any of these details

Confirm details are correct*

I confirm that all information provided is true and correct

COTA NT is committed to expanding and improving the Northern Territory Seniors Card Program. We will from time to time send out information that is relevant to senior Territorians.

You may be contacted by Seniors Card via email or phone. We will never give your contact details to a 3rd party.

Name

This field is for validation purposes and should be left unchanged.