Application form for NDIS – AQA Scheme Certification Product "*" indicates required fields Date* MM slash DD slash YYYY Type of client* New client Existing client Clients transfer from other AQA’S Request for* Verification Audit Re - Verification Provisional Audit (Required Stage 1 & 2) Certification Audit (Required Stage 1 & 2) Re - Certification Mid Term Audit Variation Name of client -Legal*Trading Business Name*Main Address*Registered/communication address*Contact person*ABN*Contact no.*NDIS Application Register Number (ARN)*E mail* Website Details of Scope of Registration ClassesAccording to the Initial Scope of Audit provided.Attach initial scope of auditMax. file size: 10 MB. Types of Participants Receiving Services- Please indicates below;Number of participants*Workers*Consultant, Advisor and Referral DisclosureIs any consultant, advisor, broker, referral source or other third party assisting the provider with this application, audit preparation, audit communication or audit process?* Yes No Please provide:Name of Consultant*Role or relationship to the provider*Phone*Email Nature of support provided*How did you hear about Australian QC?* Direct website search Previous client/provider recommendation Consultant/advisor recommendation Industry event NDIS/community network LinkedIn/social media Other Other*Has any referral fee, commission, success-based payment, gift, hospitality, benefit, discount, revenue share, lead-purchase benefit, preferred-supplier arrangement, exclusive referral arrangement or other advantage been offered, requested, promised or provided in connection with this audit enquiry or application?* Yes No Please provide details*Provider direct engagement declaration* I confirm that the provider will engage directly with Australian QC for audit quotation, audit scope, audit planning, audit communication, corrective action matters and certification-related communication. I understand that consultants or advisors may support the provider, but must not control or replace the provider's direct engagement with Australian QC.Accuracy of information declaration* confirm that the information provided in this application is accurate and not misleading. I understand that Australian QC may request further information where required to assess audit scope, impartiality, independence, conflict-of-interest risks or certification requirements.Privacy and confidentiality acknowledgement* I acknowledge that Australian QC will collect and use the information provided for audit, certification, administration, regulatory, accreditation, communication and record-keeping purposes, in accordance with Australian QC's published privacy and confidentiality statements.Applicant name*Position*Date* MM slash DD slash YYYY Signature of the authorized person*CAPTCHA
