Service Requests - Community Vision

HCP Package Provider*
For Customer*
Date of Commencement*
MM slash DD slash YYYY
Location of Services*
Services Provided To
Address*
Street Address
Phone*
Services Required
- Transport to Woodvale Social Centre
- Transport from Woodvale Social Centre
- Woodvale Social Centre Attendance
- Meals ($12) invoiced directly to member
- Refreshments ($3) invoiced directly to member
Days and Times Required (Weekly)(Fortnightly)(monthly)
Time
Sun Mon Tue Wed Thu Fri Sat Total
No. Hours
Sun Mon Tue Wed Thu Fri Sat Total
Fees
Service Units Rate Cost Cost plus GST
Total Fees
Units
Rate
Cost
Cost plus GST
By signing this service request, the parties agree that Community Vision will provide the Services specified above to the customer at the times specified and the HCP Package Provider will pay the fee specified.
Community Vision Representative (Name and Position)*
Signature*
Date
MM slash DD slash YYYY
Provider Representative (Name and Position)*
Signature*
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Service	Units	Rate	Cost	Cost plus GST