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* 1. Given Name

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* 2. Surname

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* 3. Date of Birth

Date

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* 4. Home Address

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* 5. Mobile Number

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* 6. Station

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* 7. Shift

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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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