Education Provider Education Provider Name of Course Sales Agent Name Sales Agent Email Student Details First Name* Last Name* Date of Birth* Email* Mobile* Street Address* Suburb* State* --None-- VIC NSW QLD WA SA TAS NT ACT Postcode* Citizenship Status --None-- Australian Citizen Non Citizen Marital Status --None-- Single De facto Married Dependents --None-- 1 2 3 4 5+ Residential Status --None-- Home Owner Renter Gender --None-- Female Male Payment Plan Details Agreement Date* Plan Amount* Upfront Amount* Number of Installments* Payment Amount* Payment Frequency* --None-- Weekly Fortnightly Monthly First Payment Date* Confirm Ability to Repay Plan* --None-- Yes No Bank Account Name* BSB* Bank Account Number* Employment Employment Details --None-- Full Time Part Time Casual CenterLink None Industry Time with employer --None-- Less than 12 months 12 to 24 months More than 24 months Company name Work phone number Income Details Pay Frequency --None-- Weekly Fortnightly Monthly Employment Income (Monthl) Government benefits (Monthly) Expenses Living (Monthly) Dependents (monthly) Rent (monthly) Debt obligations (monthly) Transport (monthly) Other expenses (monthly) ID Verification Drivers License Number: Drivers License State of Issue: --None-- VIC NSW QLD WA SA TAS NT ACT Drivers License Expiry: Medicare Card Name: Medicare Card Number: Medicare Card Number Position: Medicare Card Type: --None-- Green Blue Yellow Medicare Card Expiry:
