AGENT APPLICATION FORM

AGENT APPLICATION FORM
SECTION 1 - Agency Details
Name of Agency*
Name of Manager or Director*
Name of Contact Person*
Nationality
ABN*
Agency Phone Number*

Area CodePhone Number
Mobile Number*

Area CodePhone Number
Email*
example@example.com
Agency Address*
Website*
SECTION 2 - Industry Experience
How many years of experience does the company have in the educational industry*
Can you name some of the institutions you have been dealing with in Australia*
Please list two Australian institutions that can provide a reference for your company below.
Reference 1.
Company Name:*
Contact Person*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone*

Area CodePhone Number
Reference 2.
Company Name:*
Contact Person*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone*

Area CodePhone Number

SECTION 3 - Students
How many students do you expect to send QIBA in the next 12 months*
What are the nationalities of the students you will be sending?*
Other Comments
SECTION 4 - Agent Declaration
I hereby certify that our agency and all its student counselors understand the rules and regulations which apply to international students and education agents in Australia.

We regularly update our knowledge and compliance with the ESOS Act and the National Code of Practice, including Standard 4: Education Agents.

I understand I am required to provide the following documents for my application to be considered.

1. a copy of business registration certificate (mandatory, please provide below)
File Upload - Business Registration Certificate*

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2. a copy of company profile (mandatory, please provide below)
File Upload - Company Profile*

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3. two business references (mandatory, please provide below)
File Upload - Business References*

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4. copies of publications and promotional material, and any other supportive documentation.
File Upload

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Agent Signature*

Clear
Date*

MonthDayYear
Date
e: marketing@qiba.edu.au   t: +61 (2) 9267 3040

QIBA Agent Application Form V2.6

QIBA Pty Ltd CRICOS   Provider Code: 01515J

RTO Code: 5304   ABN: 35 071 667 108
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