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*

Postcode*

Citizenship Status

Marital Status

Dependents

Residential Status

Gender

Agreement Date* Total Course Cost* Deposit Amount* Number of Installments* Installment Amount* Payment Frequency*

First Payment Date* Confirm Ability to Repay Plan*

Bank Account Name* BSB* Bank Account Number*