Online Order Form

The SAS FINANCIAL YEAR ACCESS FEE is payable once per financial and must be paid before placing your first order in each financial year.
Dleivery services are not covered by the SAS FINANCIAL YEAR ACCESS FEE. Make sure you have PREPAID for postage and handling.

Membership Number:*

First Name:*

Last Name:*

Email:*

Address:

Date of Birth:*

Medicare Card Number:*

Medicare Card Expiry:*

Suburb/Town:

Postcode:

Telephone Number:*

Mobile Number:

Order for month of:

Pick up or Post:*

DISPATCH / DELIVERY ALERTS can be sent to your mobile or email. This requires that the CAV shares your mobile number or email address with AUSTRALIA POST
Do NOT send alertsDO send alerts

Code Number

Quantity

Brand Name,Item or Description

Special Instructions:

Note: To obtain more than the monthly allowance, a signed Extra Supply Form must be produced

DOUBLE ORDERS >>> Please include DOUBLE THE POSTAGE FEE

ColoVic

Online Order Form