Appointment of an
Agent/Representative
State Nomination/Sponsorship
Must be personally signed by the applicant
I
___________________________________________________________(the applicant),
(Print name)
hereby authorise the following to act on my behalf in relation to my application for visa nomination/sponsorship.
Migration agent/representative details
Name:
Company name:
Address:
State:
Country:
Telephone: (
Post Code:
)
Email address:
This migration agent/representative is
(Tick one)
MARA Registered Migration Agent
Lawyer (registered to practice in Australia)
Fee for Service Representative / Agent
If the agent operates in a country which requires registration or licensing, does the agent hold the required registration
or licensing?
Yes
No
Signature of applicant: _________________________________________ Date:
(Applicant only to sign)
/
/
(DD/MM/YY)
Print name:
Migration agent/paid representative’s declaration
I confirm that I have conducted a preliminary assessment of the applicant’s ability to meet all of the Department of
Immigration and Border Protection’s eligibility requirements.
Signature: _____________________________________________ Date:
/
/
(DD/MM/YY)
Print name:
Please note: This appointment of an agent in no way restricts or diminishes the Victorian Government’s right to make
direct contact with the applicant.
Privacy Statement
Protecting your privacy and personal information is important to the Department of Economic Development, Jobs, Transport and Resources (DEDJTR).
The Department has implemented technology and security policies, rules and measures to protect the personal information that it has under its control from
unauthorised access, improper use, alteration, unlawful or accidental destruction and accidental loss. We are committed to protecting the information we
collect and use by complying with the Information Privacy Act 2014. For more information on how DEDJTR handles your personal information go
to www.economicdevelopment.vic.gov.au/privacy.