enduring guardianship in new south wales...[insert name of person accepting appointment as enduring...
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Enduring Guardianshipin New South WalesAPPOINTMENT OF ENDURING GUARDIAN FORM
Revised November 2019
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Appointment of Enduring GuardianFor New South Wales
(Guardianship Regulation 2016, Schedule 1)
Important information to read before completing the Enduring Guardianship appointment form• AnEnduringGuardianshipappointmentisanimportantdocument.Itallows
someoneelsetomakemedicalandlifestyledecisionsonyourbehalf.Youshould getlegalormedicaladvice(orboth)beforeyousignit.
• ItisimportantthatyoutrustthepersonyouappointasyourEnduringGuardian tomakeappropriatelifestyledecisionsonyourbehalf.Itisrecommendedyou informthispersonofyourwishesaboutlifestyledecisionsandinvolvethemin discussionsaboutyourviewsorgoals.Ifthesechange,itisimportanttoletyour EnduringGuardianknow.
• AnEnduringGuardiancanonlymakelifestyledecisionssuchashealthdecisions. You shouldmakeanEnduringPowerofAttorneyifyouwantsomeonetomake financialdecisionsonyourbehalfifyoulosecapacity.
• IfyouappointmorethanoneEnduringGuardian,youshouldindicatewhetherthe EnduringGuardiansaretoactjointly,severallyorjointlyandseverally.Enduring Guardianswhoareappointedjointlyareonlyabletomakedecisionsiftheyall agreeaboutthedecision.EnduringGuardianswhoareappointedseverallyor jointlyandseverallyareabletomakedecisionsindependentlyofeachother.
• IfyouappointasubstituteEnduringGuardian*,theywillonlyhaveauthorityto actasyourguardianifthefirstappointedenduringguardian/sdies,resignsor becomesincapacitated.
• EachEnduringGuardianmustsigntheiracceptanceontheappointmentforitto beeffective.
• Ifsomeonesignstheappointmentonyourbehalf,theymustbeatleast18years old.TheymustnotbethepersonbeingappointedasanEnduringGuardian. They cannotalsowitnesstheexecutionoftheappointment.
• IfyoumarryafteryouappointanEnduringGuardianthentheappointmentwill automaticallyberevoked(unlessyoumarriedyourEnduringGuardian).
• YourEnduringGuardiancanresignatanytime,bygivingyounoticeinwriting.If you havelostcapacitytomakedecisionsatthattimethenyourEnduringGuardiancan onlyresignwiththeapprovaloftheNSWCivil&AdministrativeTribunal.
• EnduringGuardianshipappointmentsarenotautomaticallyaccessibleonanypublic register.Therefore,itisimportantthatkeypeopleareawareoftheappointmentso theycancontacttheEnduringGuardianifrequired.Youshouldprovideacopyof theEnduringGuardianshipappointmenttoyourEnduringGuardianandkeepacopy inasafeplace.Youshouldalsoletclosefriendsorfamilyknowaboutitandgivea copytoyoursolicitor,doctorandhealthservice provider.
• Furtherinformation:ThePublicGuardiancanprovideinformationonguardianship, call 02 8688 6070.NSWTrustee&GuardiancanprepareandwitnessyourEnduringGuardianship, call 1300 364 103.NSWCivil&AdministrativeTribunalGuardianshipDivisionshouldbecontactedifapersondoesnothavelegalcapacityorthereareconcernsaboutwhether someonehadcapacitywhenanEnduringGuardianshiporPowerofAttorney wasprepared,call1300 006 228.
*previouslyreferredtoasalternateguardian
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Appointment of Enduring GuardianFor New South Wales
(Guardianship Regulation 2016, Schedule 1)
1. Appointment of Enduring Guardian/s
I, [your full name]: __________________________________________________
Of [your address]: __________________________________________________
__________________________________________________________________
Occupation: _______________________________________________________
Phonenumber: ____________________________________________________
Dateofbirth: ______________________________________________________
Appoint [guardian’s name]: __________________________________________
Of[guardian’s address]: _____________________________________________
__________________________________________________________________
Phone number: ____________________________________________________
Occupation: _______________________________________________________
Appoint [guardian’s name]: __________________________________________
Of[guardian’s address]: _____________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: _______________________________________________________
Appoint [guardian’s name]: __________________________________________
Of[guardian’s address]: _____________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: _______________________________________________________
to be my Enduring Guardian/s.
2. Optional – substitute guardian
I appoint [substitute Enduring Guardian’s name]: ________________________
__________________________________________________________________
Of[address]: _______________________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: _______________________________________________________
to be my substitute Enduring Guardian.
Completeyourdetails inthespaceprovided.
Appointor – ThepersonwhomakesanEnduringGuardianappointmentisknownas theappointor.
Enduring Guardians – YoumayappointoneormorepeopletobeyourEnduringGuardian/s.
IfyouareappointingmorethanoneEnduringGuardiancompletedetailsforeachguardian.
Note:anEnduringGuardianmustbe18 yearsofageandnot haveanyconnectionwith thosewhoprovideyouwithaccommodation,healthcareorservicesforafee.
Completethissectionif youwishtoappointa substituteguardian.
AsubstituteguardianissomeoneyouappointtobeyourEnduringGuardianifyour EnduringGuardian/sdies,resignsorbecomesincapacitated.
Note:Crossoutthissectionifyoudonotwish toappointasubstituteguardian.
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3. How I wish my Enduring Guardians to act
[Complete only if more than one Enduring Guardian has been appointed]
TicktheapplicableboxbelowtoindicatewhetheryouareappointingyourEnduring Guardianstoactjointly,severallyorjointlyandseverally.
Alsoindicatebytickingtheappropriateboxwhetheryouwantyourjointly/jointlyandseverallyappointedEnduringGuardian/stocontinueintheirrolein theeventof death,resignationorlossofcapacity.
3a) Joint appointment
IappointmyEnduringGuardianstoactjointlyand[tick applicable box below]
IwanttheappointmenttobeterminatedifoneofmyEnduringGuardians dies,resignsorlosescapacity.
OR
IdonotwanttheappointmenttobeterminatedifoneofmyEnduring Guardiansdies,resignsorlosescapacity.
3b) Several appointment
IappointmyEnduringGuardianstoactseverally.
3c) Joint and several appointment
IappointmyEnduringGuardianstoactjointlyandseverallyand[tick applicable box below]
IwanttheappointmenttobeterminatedifoneofmyEnduringGuardiansdies,resignsorlosescapacity.
OR
IdonotwanttheappointmenttobeterminatedifoneofmyEnduringGuardiansdies,resignsorlosescapacity.
Tickapplicablebox/estoindicatehowyouwishyourEnduringGuardianstomakedecisionsonyourbehalf.
Jointly ThismeanstheEnduringGuardiansmustagreeandmakealldecisionstogether.
IfyouhaveappointedyourEnduringGuardianstoactjointlyyourEnduringGuardianshipappointmentwillautomaticallyterminateifoneofyourEnduringGuardians dies, resigns or becomesincapacitated.IfyoudonotwanttheappointmenttoterminatebutwanttheremainingEnduringGuardian/stocontinue in their role then ticktheappropriatebox.
Severally ThismeanstheEnduringGuardianscanmakedecisionsseparatelyof eachother.
IfyouhaveappointedyourEnduringGuardianstoactseverallyyourEnduringGuardianshipappointmentwillautomaticallycontinueifoneofyourEnduringGuardians dies, resigns or becomesincapacitated.
Jointly and severally ThismeanstheEnduringGuardianscaneithermakedecisions together or separately.
Ifyouhaveappointed yourEnduringGuardianstoactjointlyandseverallyyourEnduringGuardianshipappointmentwillautomaticallycontinueifoneofyourEnduringGuardians dies, resigns or becomesincapacitated.Ifyoudonotwanttheappointmenttocontinuebutwantittoterminatethentickthe appropriatebox.
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4. Functions and limits of my Enduring Guardian/s
ShouldIbecomeincapableofmakingmyownpersonaldecisionsI authorisemyEnduringGuardian/stoexercisethefollowingfunctions:[tick any one or more boxes below]
todecidewhereIlive
LimitsonauthorityofEnduringGuardian: ______________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
todecidewhathealthcareIreceive
LimitsonauthorityofEnduringGuardian: ______________________________
__________________________________________________________________
__________________________________________________________________
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todecidewhatotherkindsofpersonalservicesIreceive
LimitsonauthorityofEnduringGuardian: ______________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
toconsenttothecarryingoutofmedicalordentaltreatmentonme(in accordance with Part 5 of the Guardianship Act 1987)
LimitsonauthorityofEnduringGuardian: ______________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
todecide:
__________________________________________________________________
__________________________________________________________________
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EnduringGuardian/scanonlymakehealthandlifestyledecisions.YoushouldmakeanEnduringPowerofAttorneyifyouwantsomeonetomakefinancialdecisionsonyourbehalf.
SelectwhatfunctionsyouwishyourEnduringGuardian/stohaveshouldyoulosecapacitytomakedecisionsyourself.
Youmayplacelimitson thesefunctions.If you wishtoplacealimit onthefunctionprovidedetailsinthespacebeloweachfunction.
Note: YourEnduringGuardian/scanonlyexercisethesefunctionsifyouhavelostthecapacitytomakedecisionsyourself.
YoumayaddanyadditionalfunctionsyouwishyourEnduringGuardian/stoexerciseon yourbehalf.
Forexampleotherfunctionscouldinclude:
• access(makingdecisions aboutwho youshould have contactwith).
• restrictivepractices(decidingwhetherto consenttotheuseof physicaland/or chemical restraintfora limited periodtoprotect youfrom selfharm).
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5. Optional – directions to my Enduring Guardian/s
ThefunctionsofmyEnduringGuardian/smustbeexercisedinaccordancewiththefollowingdirections:
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YoumaygiveyourEnduringGuardian/sdirectionsabouthowyou wantthemtocarryouttheirfunctions.
Forexample,youcandirectthemtoconsultotherfamilymembersbeforemakingadecisionorgivedetailsaboutthekindofplaceyouwouldliketoliveifyoulostcapacity.
Note:AnEnduringGuardianmustexercisetheirfunctionsaccordingtoanydirectionsyougivethem.
Youcanonlygivelawfuldirections.YoucannotgivedirectionstoyourEnduringGuardian/stodosomethingwhichisagainstthelaw.
YoumaywishtodirectyourEnduringGuardiantorefertoyourAdvanceCareDirectivewhenmakingmedicalandhealthcaredecisions.
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6. Appointor’s signature and witness certificate
(Option – for Enduring Guardian signature/witness)
6a) My signature
Signature ___________________________ Date ________________________
6b) Optional – signature on my behalf
Theappointorinstructedmetosignthisappointmentontheirbehalf.
Signatureonbehalfofappointor _____________________________________
Date _____________________________________________________________
Signer’sfullname __________________________________________________
Signer’s address ___________________________________________________
Signer’sphonenumber: ____________________________________________
6c) Acceptance by Enduring Guardian
[Complete only if witnessed at the same time and by the same witness as appointor. Cross out if this does not apply]
IacceptmyappointmentasEnduringGuardian.
Fullname _________________________________________________________
Signature ___________________________ Date ________________________
6d) My witness certificate
I, [your full name]: __________________________________________________
Of[your address]: __________________________________________________
Phonenumber: ____________________________________________________
Occupation: Australianlegalpractitioner
RegistraroftheNSWLocalCourt
Overseas-registeredforeignlawyer
ApprovedemployeeofNSWTrustee&Guardian
Certify that [Tick applicable boxes below, cross out those which do not apply]
Theappointorappearedtounderstandtheeffectofthisinstrumentand voluntarilyexecutedtheinstrumentinmypresence.
Theappointorvoluntarilyinstructed[insert signer’s full name]
_____________________________________________________________tosigntheinstrumentontheirbehalfandthatpersonexecutedtheinstrumentinmypresence.
_____________________________________________________________
[insert name of person accepting appointment as Enduring Guardian]appearedtounderstandtheeffectofthisinstrumentandvoluntarilyexecutedtheinstrumentinmypresence.
Signature ___________________________ Date ________________________
You and your Enduring Guardian can sign this page at the same time, in front of the same witness.
If your Enduring Guardian’s signature is witnessed at a different time or by a different witness, they will need a separate witness certificate. Complete additional signature and witness certificate pages.
Note: Beforeyousignhereyoumustarrangeforawitnesstowatchyousignthisappointmentandcertifythatyouappear to understand this appointment.Yourwitnessneedstocompletetheirdetailsin section6d)below.
Ifyouarephysicallyunabletosignaskthepersonsigningforyouto signandcompletetheirdetailsopposite.Thepersonmustbeover18yearsandmustnotbethepersonbeingappointedorthewitnessasdescribedbelow.
ThewitnesscannotbetheEnduringGuardian,or asubstituteEnduringGuardian.
Thewitnessmustbe anAustralianlegalpractitioner/Registrarof theNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Only thesepersonscanwitnesstheexecutionofthisappointment.
EachEnduringGuardianmustsigntheiracceptanceontheappointmentforittobeeffective.
IMPORTANT Refer to checklist before completing this section
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7. Optional – substitute Enduring Guardian’sacceptance and witness certificate
7a) Acceptance by substitute Enduring Guardian
[Complete only if substitute Enduring Guardian appointed]
IacceptmyappointmentasEnduringGuardian.
Fullname _________________________________________________________
Signature ___________________________ Date ________________________
7b) Substitute Enduring Guardian’s witness certificate
I, [full name]: _______________________________________________________
Of[address]: _______________________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: Australianlegalpractitioner
RegistraroftheNSWLocalCourt
Overseas-registeredforeignlawyer
ApprovedemployeeofNSWTrustee&Guardian
Certify that _______________________________________________________
[insert name of person accepting appointment as substitute Enduring Guardian]appearedtounderstandtheeffectofthisinstrumentandvoluntarilyexecutedtheinstrumentinmypresence.
Signature ___________________________ Date ________________________
Note: BeforethesubstituteEnduringGuardiansignsheretheymustarrangeforawitnesstowatchthemsignthisform.Thewitnessneedstocompletetheirdetailsin section7b)below.
ThewitnesscannotbetheEnduringGuardian,or asubstituteEnduringGuardian/s.
Thewitnessmustbe anAustralianlegalpractitioner/Registrarof theNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.
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8. Enduring Guardian’s acceptance and witnesscertificate
8a) Acceptance by Enduring Guardian
[Cross out if Enduring Guardian has already signed and Enduring Guardian’s witness certificate has been completed]
IacceptmyappointmentasEnduringGuardian.
Fullname _________________________________________________________
Signature ___________________________ Date ________________________
8b) Enduring Guardian’s witness certificate
I, [full name]: ________________________________________________________
Of[address]: ________________________________________________________
___________________________________________________________________
Phonenumber: _____________________________________________________
Occupation: Australianlegalpractitioner
RegistraroftheNSWLocalCourt
Overseas-registeredforeignlawyer
ApprovedemployeeofNSWTrustee&Guardian
Certify that _______________________________________________________
[insert name of person accepting appointment as Enduring Guardian]appearedtounderstandtheeffectofthisinstrumentandvoluntarilyexecutedtheinstrumentinmypresence.
Signature ___________________________ Date ________________________
Note: BeforetheEnduringGuardiansignsheretheymustarrangeforawitnesstowatchthemsignthisform.Thewitnessneedstocompletetheirdetailsin section8b)below.
ThewitnesscannotbetheEnduringGuardian,or asubstituteEnduringGuardian/s.
Thewitnessmustbe anAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.
YourEnduringGuardian/scanresignatanytimebygivingyounoticeinwriting.Ifyouhavelostcapacityatthattime,thenyourEnduringGuardian/scanonlyresignwiththeapprovaloftheNSWCivil&AdministrativeTribunal.
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9. Additional Enduring Guardian’s signature and witness certificate/s
[Cross out if Enduring Guardian has already signed and Enduring Guardian’s witness certificate has been completed]
9a) Acceptance by Enduring Guardian
IacceptmyappointmentasEnduringGuardian.
Fullname _________________________________________________________
Signature ___________________________ Date ________________________
9b) Enduring Guardian’s witness certificate
[Cross out if Enduring Guardian’s signature already witnessed]
I, [full name]: _______________________________________________________
Of [address]: _______________________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: Australianlegalpractitioner
RegistraroftheNSWLocalCourt
Overseas-registeredforeignlawyer
ApprovedemployeeofNSWTrustee&Guardian
Certify that _______________________________________________________
[insert name of person accepting appointment as Enduring Guardian]appearedtounderstandtheeffectofthisinstrumentandvoluntarilyexecutedtheinstrumentinmypresence.
Signature ___________________________ Date ________________________
Note: Beforeyousignhereyoumustarrangeforawitnesstowatchyousignthisform.Thewitnessneedstocompletetheirdetailsinsection9b)below.
Thewitnessescannotbe theEnduringGuardian,orasubstituteEnduringGuardian/s.
Thewitnessmustbe anAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.
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9aa) Acceptance by Enduring Guardian
[Cross out if Enduring Guardian has already signed and Enduring Guardian’s witness certificate has been completed]
IacceptmyappointmentasEnduringGuardian.
Fullname _________________________________________________________
Signature ___________________________ Date ________________________
9bb) Additional Enduring Guardian’s witness certificate
[Cross out if Enduring Guardian’s signature already witnessed]
I, [full name]: _______________________________________________________
Of[address]: _______________________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: Australianlegalpractitioner
RegistraroftheNSWLocalCourt
Overseas-registeredforeignlawyer
ApprovedemployeeofNSWTrustee&Guardian
Certify that _______________________________________________________
[insert name of person accepting appointment as Enduring Guardian]appearedtounderstandtheeffectofthisinstrumentandvoluntarilyexecutedtheinstrumentinmypresence.
Signature ___________________________ Date ________________________
Note: Beforeyousignhereyoumustarrangeforawitnesstowatchyousignthisform.Thewitnessneedstocompletetheirdetailsinsection9bb)below.
Thewitnessescannotbe theEnduringGuardian,orasubstituteEnduringGuardian/s.
ThewitnessmustbeanAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.
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Enduring Guardianship Checklist
CheCklistPlease read below and tick to ensure you have completed all details of your Enduring Guardianship appointment correctly.
1. IhavespokentomyproposedEnduringGuardian/sanddiscussedthisappointmentwiththemtoensuretheyarewillingandabletotakeonthisroleandexercisethefunctionsIwishtogivethemasdescribedin sections3and4.
2. ItrustmyEnduringGuardian/sandhavespokentothemaboutthekindoflifestyledecisionsIwishthemtomakeonmybehalfshouldIlosecapacity.If thesechange,IunderstanditisimportanttoletmyEnduringGuardian/sknow.
3. IhavediscussedtheappointmentofmyEnduringGuardian/swithmyclosefriends/familytoletthemknowofmydecisiontoappointanEnduringGuardian.
4. Ihaveconsideredtheoptioninsection2ofappointingasubstituteguardianshouldmyfirstappointedEnduringGuardiandie,resignorbecomeincapacitated.
5. IhaveindicatedhowIwishmyEnduringGuardianstoact(i.e.jointly,severallyorjointlyandseverally)bycompletingsection3.
6. IunderstandIcanasksomeonetosignthisappointmentonmybehalfinsection6ifIamphysicallyunabletosign.Thispersonmustbeovertheageof18andcannotbemyEnduringGuardian/sorawitnesstothisappointment.
7. Iunderstandthecertificateofwitnessneedstobecompletedbyaneligiblewitness,i.e.anAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee &Guardian.
8. IunderstandmyEnduringGuardian/sneedtosigntheiracceptanceoftheEnduringGuardianappointmentbeforeitcanoperate.
9. IunderstanditisimportanttogiveacopyofthisEnduringGuardianshipappointmenttomyEnduringGuardian/sandotherrelevantpeople,suchasmyGPandattorney,andIwillkeepacopyinasafeplace.ThereisnopublicregisterforEnduringGuardianshipappointments.
10.IunderstandthatifImarry,theEnduringGuardianshipappointmentwillberevokedunlessIammarryingmyEnduringGuardian.
11.Iunderstanditisadvisabletogetmedicalandlegaladvicebeforesigningmy EnduringGuardianshipappointment.
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I your full name: Of your address 1: Occupation: Phone number: Date of birth: Appoint guardians name: Of guardians address 1: Of guardians address 2: Phone number_2: Occupation_2: Appoint guardians name_2: Of guardians address 1_2: Of guardians address 2_2: Phone number_3: Occupation_3: Appoint guardians name_3: Of guardians address 1_3: Of guardians address 2_3: Phone number_4: Occupation_4: I appoint substitute Enduring Guardians name 1: I appoint substitute Enduring Guardians name 2: Of address 1: Of address 2: Phone number_5: Occupation_5: to dec: OffLim 1: to dec_2: OffLim 1_2: to dec_3: OffLim 1_3: to consent to the carrying out of med: OffLim 1_4: to dec_4: Offi 1: w 1: Date: f of appointor: Date_2: name: Signers address: Signers phone number: name_2: Date_3: I your full name_2: Of your address: Phone number_6: Austra: OffRegistrar of the NSW Loca: OffOverseasregistered fore: OffApproved emp: OffThe appointor appeared to understand the effect of this instrument: OffThe appointor voluntar: Offgn the instrument on their beha: undefined: instrument in my presence: Date_4: name_3: Date_5: I full name: Of address 1_2: Of address 2_2: Phone number_7: Austra_2: OffRegistrar of the NSW Loca_2: OffOverseasregistered fore_2: OffApproved emp_2: OffCertify that: Date_6: name_4: Date_7: I full name_2: Of address 1_3: Of address 2_3: Phone number_8: Austra_3: OffRegistrar of the NSW Loca_3: OffOverseasregistered fore_3: OffApproved emp_3: OffCertify that_2: Date_8: name_5: Date_9: I full name_3: Of address 1_4: Of address 2_4: Phone number_9: Austra_4: OffRegistrar of the NSW Loca_4: OffOverseasregistered fore_4: OffApproved emp_4: OffCertify that_3: Date_10: name_6: Date_11: I full name_4: Of address 1_5: Of address 2_5: Phone number_10: Austra_5: OffRegistrar of the NSW Loca_5: OffOverseasregistered fore_5: OffApproved emp_5: OffCertify that_4: Date_12: 1 I have spoken to my proposed Enduring Guard: Off2 I trust my Enduring Guard: Off3 I have discussed the appointment of my Enduring Guard: Off4 I have cons: Off5 I have ind: Off6 I understand I can ask someone to s: Off7 I understand the cert: Off8 I understand my Enduring Guard: Off9 I understand: Off10 I understand that: Off11 I understand: OffOf your address 2: Existing 2: Off3a_: Off3b_: Off