Agent Application Reference Check 1 Step 1 Agent Application Form Legal Name Trading Name Business Registration Number (country of Origin) Australian Business Registration Number Registered Physical Address0 / Is Postal Address same as registered address?YesNo Registered Postal Address0 / Telephonecall Emailemail Website Address Agent's Principal Executive Officer Name Emailemail Contact Numbercall Agent's Day to Day Contact Name Emailemail Contact Numbercall Agent’s nominated recruitment staff involved in ETEA student marketing Name Emailemail Name Emailemail Name Emailemail Please list the countries where you will market ETEA’s courses. Nominate ETEA courses and code numbers you are interested in representing in your market and why? (Please attach additional page if insufficient space provided)0 / About you: Number of Students sent to Australia last year and this year until now Primary Business Number of student Counselling staff Services Provided to Students Member of Associations Years in education consultation Have you previously worked in conjunction with another education agent?YesNo If Yes, what is the name of that agent? DECLARATION: I am interested in representing Education Training & Employment Australia as an education agent and I agree to do so in an honest and professional manner. Name of Authorised Officer Signature Of Agents Authorised OfficerI agree to the terms and conditions(Sign Here)Clear Signature If you can't draw signature, please upload your signature below. cloud_uploadSignature Datedate_range Please upload all supporting documents such as Marketing Plan, Agent Profile, MARA Registration, ABN/ACN Registration, Company registration certificate. cloud_uploadUpload Submit Form keyboard_arrow_leftPrevious Nextkeyboard_arrow_right