Provider Application

Please fill in the NDIS Provider Application to the best of your ability. You will need your business name, ABN, provider number, qualifications, insurance, and references. If you don't have these you can be working towards them.

This application should take approx. 10 mins.

PERSONAL INFORMATION

Full Name *

Organisation (Business Name)

ABN (Australian Business Number)

Email *

Mobile Phone Number *

Address *

City *

State *

Postal Code *

NEXT OF KIN (PERSON TO BE CONTACTED IN CASE OF AN EMERGENCY)

First Name - Next of Kin *

Last Name - Next of Kin *

Address - Next of Kin *

City - Next of Kin *

State - Next of Kin *

Postcode - Next of Kin *

Mobile Phone Number - Next of Kin *

Relationship - Next of Kin *

PROFESSIONAL QUALIFICATIONS

What service would you like to offer? *

Please Specify your Qualification/s *

Please Upload all Relevant Documents Here (copies of certificates etc). All documents need to be choosen at once and uploaded together. (eg: add all your documents to one folder and then upload).

Upload Links to Qualifications

INSURANCE

Do you have Insurance?

Professional Liability Insurance

Comprehensive Car Insurance

Working towards Insurance

None/Other

Insurance Expiry Date/s

Upload Copy of Insurance/s. All documents need to be choosen at once and uploaded together. (eg: add all your documents to one folder and then upload).

Upload Links to Insurance/s

Please tell us why you would like to offer your services to Stones Disability Services.

PERSONAL STATEMENT

Write Below *

EMPLOYMENT HISTORY

Upload CV. All documents need to be choosen at once and uploaded together. (eg: add all your documents to one folder and then upload).

Upload Link - CV

Current/Most Recent Role *

Role/Job Title
Organisation
Date From
Date To
Key Resposibilities
Reason for Leaving

Employment History - Free Fill

Please provide two references and let them know we will be calling.

REFERENCES

Reference 1 *

Reference 2

IDENTIFICATION

ID (100 points) *

Passport - Foreign - Current (50 points)
Passport - Australian - Current or Expired within 2 years but not cancelled (50 points)
Australian Citizen Certificate (50 points)
Australian Drivers Licence/Learners Permit (50 points)
Full Birth Certificate (50 points)
Medicare Card (25 points)
Property Lease Agreement for Current Address (25 points)
Utility Bill Showing Current Address (25 points)

POLICE CHECK

Have you completed a Police Check? *

Yes

No

Processing

Upload Police Check Certificate. All documents need to be choosen at once and uploaded together. (eg: add all your documents to one folder and then upload).

Upload Link to Police Check

SIGN AND SUBMIT

Application Signature *

Clear

Captcha

Provider Application

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