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1. Given Name (Required.)

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2. Surname

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3. Date of Birth (Required.)

Date

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4. Home Address (Required.)

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5. Mobile Number (Required.)

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6. Station (Required.)

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7. Shift (Required.)

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8. Do you have unpaid travel allowance?

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9. From what date are you owed allowances?

Date

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10. What type of allowances are you owed?

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11. Does your travel claim include the carrying of gear?

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12. Does your travel claim include travel to/from Port Pirie?

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13. Are you missing meal allowances related to travel?

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14. Have you received any response from the MFS about your claims for travel? If so, please provide information about the response.

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15. Have you received a payment that was incorrect that remains unresolved? If so, please check all that apply.

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16. Did you receive any payment of travel or related allowances in December/January?

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17. If you received payment of travel in December/January, did this pay your owed travel allowance balances in full?

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18. Do you know the monetary value of your outstanding allowances?

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19. If yes to question 18, please provide details of the value.

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