Education Provider Education Provider: Name of Course Sales Agent Name Sales Agent Email 1. Payer 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 Gender: --None-- Female Male Other Student Name (if different from Payer Name) 2. 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:
