STUDENT DETAILS
University of Canberra
Students ID:
Email:
Family Name:
Given Names(s):
Date of Birth:
Phone:
Course Name:
Course Start Date:
PREVIOUS AGENT DETAILS
Agent Name:
Address:
Country:
Post Code:
NEW AGENT DETAILS
Agent Name:
Contact Person:
Position Title:
Signature:
Date:
REASON FOR AGENT CHANGE (CIRCLE OR TICK ANSWER IF OTHER PLEASE EXPLAIN)
Not responsive to my requests :
Provided wrong or misleading information :
Other:
STUDENT DECLARATION AND SIGNATURE
You are entitled to protection of the personal information you provide to the University of Canberra (UC) under the Information Privacy Act 2014. This means that
any personal information we collect about you is treated according to the law and applicable policy.
We may disclose your personal information for the purposes of your application to study at UC as necessary, or where required or permitted by law. We disclose
some personal information we hold to other parties. For example, if your studies involve an organisation related to the University, such as the University of Canberra
College, a pathway provider or an external research or teaching centre, your personal information may be disclosed to that organisation. We may also disclose your
personal information to overseas organisations or regulators. For example, if your studies involve an overseas organisation related to the University, your personal
information may be disclosed to them.
If your request to change agent is successful, we will disclose your personal information to your nominated agent, including your personal details and information
about your academic progress. See UC’s Privacy Policy (available at www.canberra.edu.au/privacy) for more information.
We have a range of IT, procedural and contractual safeguards in place to protect your personal information. If we do not disclose your personal information, your
nominated agent will not be able to act for and on your behalf in relation to your application to study at UC.
By signing below, you consent to UC using and disclosing your personal information as described above and in UC’s Privacy Policy. For more information, please
telephone UC’s Privacy Contact Officer on 02 6201 5111 or email at [email protected]
Signature:
Date:
Please email the completed Form to UCagents.Commissions@ canberra.edu.au
UC INTERNAL USE ONLY
Approved:
Not Approved:
Approver’s Name:
Commission Allocation:
Date:
Signature:
Comments:
T: +61(0) 2 6201 5111 W: www.canberra.edu.au I University of Canberra Locked Bag 1 ACT 2601 Australia
Australian Government Higher Education Registered Provider Number: University of Canberra (CRICOS) # 00212K I This form is correct as of 01.04.2016