To be a part of the LiveLife Community Support Program please complete the below submission form. Contact Name* Phone* Email* Charity, Community or Support Group Name* Please describe your Charity, Community or Support Group (in 50 words or less)* Which local LiveLife Pharmacy would you be able to visit for a photo with the LiveLife Team and to sign for the funds?* Bank Account Details* BSB* Account Number* Account Name* Account Holder Verification In order to verify the account holder of the above details we require a copy of a deposit slip or the top of a bank account statement to be attached. (max file size 1MB)* Proposed use of funds (50 words or less)* Logo Please upload a copy of your logo and/or relevant image of your local community group so we can promote your cause. (Optional, max file size 1MB) I/we agree to come in-store for a photo with the LiveLife team, or to send a logo and/or a relevant image/s of our community group to LiveLife. If we do not come in-store for a photo or send a logo or relevant image/s to LiveLife, we agree that LiveLife has permission to use a logo/image that we have posted publicly on our website, Facebook page or other social media page. We understand that LiveLife may use this image on its website, social media, as well as other online and print platforms to help promote our community group, and LiveLife's contribution to our community group.* Δ
