Applicant Authority Form - Law Access Western Australia

Applicant Authority

A form acknowledging the conditions of service of Law Access and providing authority for a nominated contact and in relation to information.

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This field is for validation purposes and should be left unchanged.
You can complete the applicant authority online, or you can downloaded as a PDF (which can then be uploaded or emailed or posted to us).(Required)
- Complete the online form
- Download the PDF
- Upload completed PDF
Download the PDF form
Upload completed PDF here(Required)
Max. file size: 10 MB.
First name(Required)
Last name(Required)
Date of Birth(Required)
Email(Required)
Enter Email Confirm Email
Phone
Law Access does not provide legal services(Required)
• Law Access does not provide legal advice or representation. Law Access will not act as your lawyer.
• You remain responsible for meeting any limitation dates or important dates in your matter and attending any hearings.
• If you are eligible, Law Access will try to find a lawyer willing to help without charging their usual fees.
• If we find a lawyer or law firm willing to help, you are responsible for negotiating the terms of your engagement with them.
• Do not rely on Law Access to provide legal advice or representation. No cause of action in negligence for providing or failing to provide legal advice arises from Law Access processing or assessing your application.
I accept.
False Statements(Required)
• Law Access needs to know information about your circumstances and legal issue to assess whether you are eligible for assistance.
• You must provide true and complete information.
• If we find your information is false or you have left anything out, you will not get help from Law Access or pro bono lawyers.
I accept.
Nominated contact
If you would like us to contact someone else on your behalf about your application, please tick the box to provide their name and contact details below.
- Nominate contact
Contact's first name(Required)
Contact's last name(Required)
Relationship to me(Required)
Email(Required)
Phone
My Information(Required)
1. Law Access relies on the information that I provide and I must provide full disclosure of all relevant information to Law Access to process my application.
2. Law Access may need to get other information about me or my legal issue and I provide the consent below for my information to be shared with Law Access.
I authorise and request any person or organisation holding relevant information about me to provide Law Access any information and documents Law Access request in order to assist Law Access to process my application for pro bono assistance and collect information about outcomes.
3. Law Access may share information about my application with others for the purpose of processing my application.
4. Law access may publish information about my application for reporting, marketing and promoting Law Access work and pro bono practice but when they do so they will not use my name or other information that would allow me to be identified unless I specifically agree to be identified.
5. Law Access will keep my information confidential and use it only for my application and not for processing any application by any other applicant.
6. Law Access may receive or possess information for others whose interest conflict with mine and will not use their information in processing my application. Law Access may still process applications when this happens.
7. Where there is a conflict of interest, Law Access may refer my application to an independent external party for assessment.
I accept.
Signature(Required)