Full name

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Number of people in your household (including adults and children):

Pre-orders Preferred ID Pre-orders Preferred ID Medicare cardDriver's LicenseOther

If you are using another ID that is not listed, Please specify

Gender GenderMaleFemaleChoose not to say

Home/Postal Address

Suburb

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Phone Number

Please select the food/items you need: Please select the food/items you need: White flour - 5 kg Semolina flour – 5 kg Cassava flour (For Fufu) Tea bags Salt Sugar Cocoa powder Greek yoghurt Peanut butter Full fresh milk Full cream milk – Lactose free Low fat milk Dry beans Lentils Halal meat (depends on availability) Irish potatoes Sweet potatoes Okra Molokhia Onions Tomatoes Cucumbers Carrots Pumpkin Eggplants Insect/Mosquito repellent Anchovy Wheatbix Rice bubbles Fruit loops Body wash/shower gel Laundry detergent Dishwashing liquid Toothpaste for adults Toothpaste for children Baby wipes Other

Please specify what other food/items you need

5kgs Rice (please select type of rice) 5kgs Rice (please select type of rice)JasmineBasmatiSunriseNot needed

10kgs Rice (please select type of rice) 10kgs Rice (please select type of rice)JasmineBasmatiSunriseNot needed

5kgs Maize flour (please select type of flour) 5kgs Maize flour (please select type of flour)Mealie/CornUgali

Cooking oil- 2 Litres (please select type of oil) Cooking oil- 2 Litres (please select type of oil)Sunrise oilPalm oilVegetable oilNot needed

Cooking oil- 3 Litres (please select type of oil) Cooking oil- 3 Litres (please select type of oil)Sunrise oilPalm oilVegetable oilNot needed

Frozen food- Please select below: Frozen food- Please select below: Taro Bananas/plantain Cassava Maize Yams Corn Not needed

Children's snacks- Please select below (tbc, if available ): Children's snacks- Please select below (tbc, if available ): Chocolates Candies Ice cream

Do you have any disability? Do you have any disability? Yes No

Please briefly explain

Any dietary requirements? Any dietary requirements? Yes No

Please briefly explain

Are you in quarantine due to travel or infection of the virus? Are you in quarantine due to travel or infection of the virus? Yes No

How did you hear about us: How did you hear about us: AfriAus iLEAC FARREP/Monash Health Gippsland Sudanese Association Liberian Youth Assosiciation of Victoria Pan African Australasian Diaspora Network South East Victoria Women Youth & Children Association Sudanese Mothers' Coalition in Victoria United Muslim Sisters of Latrobe Valley Victoria Association of Malawians and Friends Other

Please specify how

The collected information will be used for the sole purpose of delivering and managing the CALD Communities Taskforce – Pop-Up Food Markets Program. Hence, I a) Have read the information in this form/The information has been read to me and I understand it. b) Understand this information remains valid for the use of the specified Activity. c) Consent to LUVPACKS Partnership to disclosing my personal information to the Sponsor as necessary for purposes of COVID-19 Response. The collected information will be used for the sole purpose of delivering and managing the CALD Communities Taskforce – Pop-Up Food Markets Program. Hence, I a) Have read the information in this form/The information has been read to me and I understand it. b) Understand this information remains valid for the use of the specified Activity. c) Consent to LUVPACKS Partnership to disclosing my personal information to the Sponsor as necessary for purposes of COVID-19 Response. I understand

Checklist Checklist I have read the information in this beneficiary form/The information in this beneficiary form has been read to me and I understand it. I have completed all the sections of this form. Any corrections have been initialled and dated by me (or assistant).