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* Total Course Cost* Deposit Amount* Number of Installments* Installment 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 Time with employer --None-- Less than 12 months 12 to 24 months More than 24 months Company name Income Details (Monthly) Employment Income (Monthly) Government benefits (Monthly) Expenses (Monthly) 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:
