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;Disability types*Age groups*Diversity factors* Indigenous participants Culturally and linguistically diverse Other category*Number of participants*Workers*Geographic coverage of services provided*Consent* We hereby declare that the information given above is true as per best of my knowledge and we are bound to follow the rules of certification.*Name*Designation*Signature of the authorized person*CAPTCHA