IDP Nomination Form

THIS FORM VERIFIES THAT THE STUDENT BELOW HAS NOMINATED IDP EDUCATION
AS HIS/HER AUTHORISED AGENT FOR STUDENT RECRUITMENT PURPOSES.

This form is to be used for cases A. Changes existing agent to IDP or

where a student:
B. Requests IDP services post applying direct to the
institution
Section A: Student Details
Student Family Name: Talebi
Student Given Name: Alireza
Student Date of Birth: 22/06/1985
Institution Student

No/Ref:
Course Name: Master of Engineering management

Section B: IDP Office Details

Name (city): Tehran
Mailing Address: No3, Sanaz dead-End, Ghalandari St, Mirzapour St, Shariati Ave.

Email Address: Sara.farazi@idp.com

Phone Number: 00989125852461
Fax Number:
Counselor Name: Sara Farazi
Section C: IDP Services
Information & Advice to prospective students
IDP Service/s Provided i.e. counseling

(Please tick) Application Processing Assistance

Pre-departure Assistance
e.g.: visa assistance, health insurance

Service level Full Partial

Section D: Student Declaration

I __Alireza_________ , wish to confirm that IDP Education Pty Ltd in _Tehran____,
is my agent for student recruitment purposes.

Signature
Date

Section E: Institution Declaration

Please fax or email the completed form to IDP Education -office details are above
I hereby recognize IDP Education Pty Ltd as the agent for this student and confirm that it is eligible for
commission at the service level indicated above
Institution Representative Name:
Position Title :
Signature of Institution's Representative:
Date:
Not Approved Comments:

Version 1 March 2012