How to Apply

CLIENT CONTACT INFORMATION

Name of Client

First Name

Last Name

Phone

Date of Birth

Address

WORK AND INCOME CLIENT INFORMATION (please fill in if applies)

Referring Organisation / WINZ office / or self referral

Work and Income Client Number (if you have one)

Do you currently receive a benefit?

CLIENT SIZE INFORMATION

Size

Client waist size

Select waist size in inches

Shoe size

ADDITIONAL INFORMATION

Job Seeking Industry

Please select the industry:

Ethnicity

Comments

Please add any extra comments here

Privacy

The information on this form is collected for Fix Up, Look Sharp use only. I give permission for Fix Up, Look Sharp to use my before and after photos on their website and social media platforms.

Agree

Disagree

Referral Form