ACBI Change of Agent Request Form

ACBI Change of Agent Request Form
Student Details
Name*

First NameLast Name
Offer ID OR Student ID*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Agent Details
Name of Current Agency*
Please write a short paragraph to explain why you are requesting to change to another agent.*
New Nominated Agent*
New Nominated Agency Branch Address*
Applicant Declaration & Signature
I request that the above Nominated Agent act for and on my behalf in relation to my application/current studies at the Australian College of Business Intelligence (ACBI).

I acknowledge that the reason I have requested to change agency may be disclosed to my current agent.

I give my consent to the provider to disclose my personal information to the above Nominated Agent for the purposes of my application/studies and otherwise in accordance with the provider's Privacy Policy which is available at the link below:

https://www.acbi.edu.au/wp-content/uploads/2021/11/PrivacyHandling-converted-converted.pdf
Name of Student*

First NameLast Name
Signature of Student*

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Date*

MonthDayYear
Date
NEXT SECTION FOR OFFICE USE ONLY
Approving Staff Name

First NameLast Name
Signature of Approving Staff

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Date

MonthDayYear
Date
Should be Empty:

Student Details