I declare that:

• The information I’ve provided in this request is correct and complete;
• I am not married or in a de facto relationship;
• I agree to be bound by the Fund Rules and Constitution of Union Health as amended from time to time;
• I am aware of that details of Union Health's privacy policy and I consent to Union Health collecting, using and/or disclosing my personal information for the purposes stated in the policy; and
• I am aware that I have a 30 day cooling-off period