Learning Centre Registration

The Provider / Company

Registered name *

Trading name *

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Contact Details

Name *

Position *

Portal Address *

Street Address *

Telephone No *

Mobile Phone *

Facsimile

Email *

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Status

Body Corporate *

Trustee Company *

Other

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Company Details

ACN *

i.e.MyCOID/ Business Registration Number

Place of incorporation *

Date of incorporation *

Name and address of registered office *

Principle place of business *

Checkboxes *

I agree and proceed to be IEG Learning Center

Title *

Printed name *

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Registration Details

Is the company / provider registered for education purposes as an Education Provider or Registered Training Organisation as registered by state and territory training authorities to deliver nationally recognised Higher Education programs/training? *

Yes

Registration/ Licence Number *

Name of Governing Authority issuing Registration / licence *

State or Territory of registration *

Date of Registration & Validity *

Date of last Audit / Review *

Does the company / provider plan to gain registration? *

Yes

If yes, above, when is this expected to be completed? *

Has the company / provider previously had an Education Provider (EP) License / Registered Training Office (RTO) status that has been revoked or suspended? *

Yes

Previous Registration/ Licence No *

Reason for revocation or suspension *

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Company Directors

Title *

Name *

Occupation *

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Are any of the registered Directors on additional Boards? If so please list

Title

Name

Additional Board(s)

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Do any of the registered Directors have ownership or controlling interests in entities not associated with the entities providing this Due Diligence? If yes, please list the associated entities:

Title

Name

Additional information

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Describe the structure of the Board of Directors and its relationship with the organisational structure of the company / provider? *

(If appropriate, please provide an organisation chart showing the structure and reporting lines) by uploaded the file below.

File Upload

If more than one file, kindly please zip and upload.

Authority to execute: Describe fully the nature of the authority of the person signing and authorising this Due Diligence. What is the nature of this authority, which may be required for perusal? *

Please provide details of any engagements, obligations or commitments that the Company/Provider or any of its partners, staff or consultants have or are likely to acquire which may give rise to any actual or perceived conflict or interest with any of the services that may be required in connection with the proposed contract. *

Please advise of details of any strategy for identifying, managing and preventing conflicts of interest. *

The Provider promises that it, and its partners, staff and consultants, do not own and are not aware of any actual or potential conflicts of interest that may arise between IEG Campus and the Company / Provider unless otherwise stated. *

I agree and proceed to be IEG Learning Center

Financial Details

Note: For the purposes of this Due Diligence document “associated entity” bears the same meaning as it does in section of your operating country’s Corporations Act.

Are there any significant events, matters or circumstances which have arisen since the end of the last financial year which may affect the operations of the Company / Provider? *

Yes