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 Δ