POWERS OF ATTORNEY QUESTIONNAIRE

Date

Your Full Name

Address

Date Of Birth

Mobile/Other Telephone No

ENDURING POWER OF ATTORNEY You can choose more than one attorney if desired. Please list below who you are appointing as your attorney/s?

Attorney (1)

Full Name Attorney (1)

Address

Date of Birth

Email Address

Mobile/Telephone No.

Act jointly?
Act jointly & severally?

Attorney (2)

Full Name Attorney (2)

Address

Date of Birth

Email Address

Mobile/Telephone No.

Act jointly?
Act jointly & severally?

In the event your appointed attorney/s cannot or is not willing to act as attorney/s, please list below who you would like to appoint as an alternative attorney/s

“Alternative” Attorney (1)

Full Name (Alternative Attorney (1))

Address

Date of Birth

Email Address

Mobile/Telephone No.

Act jointly?
Act jointly & severally?

“Alternative” Attorney (2)

Full Name ( Alternative Attorney (2))

Address

Date of Birth

Email Address

Mobile/Telephone No.

Act jointly?
Act jointly & severally?

Select below when the Power of Attorney is to commence?

Immediately
Upon you losing capacity
At another specific time

Provide any specific instructions to give your power of attorney/s

You place the following limits and/or conditions on the authority of your attorney/s (if applicable)

MEDICAL TREATMENT DECISION MAKER

You can nominate more than one Medical Treatment Decision Maker. However, please note that only one person can act as decision maker at any one time. Accordingly, the first person listed as your Medical Treatment Decision Maker, will be the first point of contact if a medical decision is required and you lack capacity.