AGENT APPLICATION FORM 2021
All questions must be answered and details filled in, if not applicable please mark N/A.
Agent Details
Trading Name
Legal Name
ABN
E mail Address
example@example.com
Contact Person
Name
Title
Mr
Ms
Other
Australian Office Address
Telephone
-
Country Code
-
Area Code
Phone Number
Overseas Office Address if applicable
Agent market
How did you hear about us?
Friends/relatives
Website
Newspaper
Australian Embassy
Austrade
Agent - please provide name:
Other
Reference check
In order to become of one our official representatives (agents) CTIC requires references from your current partners (Colleges/Institutes/Universities, etc. Please provide details of 2 referees we can contact:
Referee 1
Institution Name
Referee 1
Name of Referee
Referee 1
Position
Referee 1
E mail: example@example.com
Referee 2
Institution Name
Referee 2
Name of Referee
Referee 2
Position
Referee 2
E mail: example@example.com
Agent Signature
Date
-
Day
-
Month
Year
Preview PDF
Submit
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