Electronic Funds Transfer Application Form
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Electronic Funds Transfer Application Form (PDF 120kb)
Document Type: Form
Keycode: FOR553/03/02.08
Category: Health Care Providers
Publication Date: 19 March 2008
Date First Published: 11 October 2006
Summary: This form allows WorkSafe Victoria to deposit funds directly into a nominated provider's account.
About this form
Personal information collected on this form will be used for the purposes of allowing Victorian WorkCover Authority (VWA) to make payments to the provider. It may be disclosed to the financial institution nominated on this form.
