Fillable Disclosure of Information and Proxy Authorisation Form (Curtin University of Technology)

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Disclosure of Information and Proxy Authorisation Form (Curtin University of Technology)

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Country of origin: AUSTRALIA
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(Proxy End Date)
Disclosure of Information and Proxy Authorisation Form
To be completed by the student
Student ID: Date of Birth:
Family Name:
Given Name(s):
Residential Address:
Telephone Number:
Post Code:
(Full Name of Student)
(Full Name of Proxy) (Driver's Licence/Passport /Curtin Student ID of Proxy)*
(Residential Address of Proxy)
Date:
Date:
Student Signature:
Proxy Signature:
Enquiry
Enrolment
Student Fees Account
Award Details
Specific Information Only:
Collection
Letter to Confirm Enrolment
Letter of Course Completion
Visiting Relations Letter
Academic Transcript
Graduation Statement
Graduation Tickets/Regalia
Award Certificate (may include Academic
to act on my behalf in all matters related to my studies at Curtin University
OR
to perform the following actions, on my behalf (please tick relevant boxes below):
Transcript and Graduation Statement)
Payment Receipt
This authorisation is valid until:
End date
Continuing - will remain in effect while the
student is enrolled in studies at Curtin University
OR
Students under the age of 18 must have this form co-signed by a parent or legal guardian.
Email:
hereby authorise the individual below,
I,
D D M M Y Y Y Y
*All authorised proxies must present the photographic identification stated above when verifying identities to staff.
This form needs to be submitted from the Curtin student email address. If this is not possible, the proxy needs to provide an
original, certified or colour scanned original copy of the Curtin students’ Driver’s Licence or Passport (must contain Curtin
students’ signature for verification purposes. Curtin University scanned documents and certification requirements and
guidelines can be found here http://courses.curtin.edu.au/course_overview/admission-criteria/scanned-documents.cfm
The information provided on this form will be retained by the University and handled in accordance with the University’s
policy on the management and disclosure of personal details and information.
Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J (WA)
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Disclosure of Information and Proxy Authorisation Form (Curtin University of Technology)

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Completed 16 February 2021

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