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COMPANY PROFILE
Company Name*
Address*
Street AddressCityState / Province / RegionZip / Postal CodeCountry
Postal Address (If different to above)
Street AddressCityState / Province / RegionZip / Postal CodeCountry
Phone Number*
Fax Number
Website
Main Contact Person*
Position*
Phone Number*
Email*
Business Registration no.
(If located in Australia)
Business Registration Certificate
(If applicable)

REFEREES
Please list down two referees that can vouch for your agency records as an education agent representing their Institute. One of the referees must be from an Educational Institute in Austraila.
Referee (1)
Name*
Position*
Organization*
Email*
Address*
Street AddressCityState / Province / RegionZip / Postal CodeCountry
Phone*
Referee (2)
Name
Position
Organization
Email
Phone
Address
Street AddressCityState / Province / RegionZip / Postal CodeCountry
DECLARATION
I am interested in representing Menzies Institute of Technology as an Education Agent and I agree to do so in an honest and professional manner. I have read the National Code of Practice for Registration Authorities and Providers of Education and Training to Overseas Students (2007) and agree to adhere to the relevant Standards.

I agree to:
- Regularly monitor policies and changes to the policies as reported on the DIAC website.
- Regularly monitor policies and regulations and changes to these policies and regulations as reported on the DEEWR website.
Enter Your name*
Date*

COMPANY PROFILE