Make A Difference Application Form

Make A Difference Application Form

Apply to receive a donated service

Would you or someone you know who is living with a disability benefit from a free mobile service?

Fill out the application form below and we’ll assess your application. If you’re eligible, you will be added to our waiting list to receive a free 12 month subscription to our $15 Light SIM pack plus our full 24/7 HELP package (including GPS locator service, 24/7 HELP service and range of accessible apps).

Please fill out all sections marked with an asterisk *

Contact details

Title*

First name*

Last name*

Date of birth*

Contact phone number*

Contact email

Address*







Proof of eligibility*

We donate free mobile services to successful applicants who live with disability. We'd love to offer everyone who applies a free service, however, unfortunately the demand is far greater than our ability to supply free services. In order to ensure that the Make a Difference Program is meeting its primary objective we ask all applicants to provide some written proof that they live with disability.

This can be in the form of:

  • Pension Card (listing the Disability Support Pension)
  • A letter from your Service provider
  • Or some other form of proof

File should be no bigger than 3MB


Tell us a little bit about you. What do you like to do? How would a donated service help you. (100 words Max)

I agree to the Terms & Conditions of the Jeenee Mobile Make A Difference Program