SAC Registration – IEG Campus

SAC-Register Form

Company Details

Business Name *

Business Registration / Licence Number *

Name of Governing Authority issuing Registration / Licence *

State of Territory of Registration *

Date of Registration & Validity *

Date of Last Audit / Review *

Address *

Address

City

State/Province

Zip/Postal

Country

Body Corporate *

Principle place of business *

Does the company / provider plan to gain registration *

Yes

If Yes, When is this expected to be completed

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.

Website *

Email *

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

I agree and proceed