Form A - Individual Tutors Registration Form

Private Tuition Coordinator

AES Private Tuition Provider Registration - FORM A

Individual Private Tutors Use this form if you are an individual tutor proposing to work directly for the Private Tuition Coordinator (PTC). Send this form via post, fax or email to the PTC. The PTC will register you on the AES database. AES Private Tuition Coordinator Curriculum Corporation Reply Paid 177 CARLTON SOUTH VIC 3053 Fax: 1800 620 970 Email: [email protected] Name of person completing this form: Contact phone number:

     

     

1. LEGAL ENTITY PROVIDING SERVICES Curriculum Corporation will only enter into a Letter of Agreement with a legal entity. That may be a company, a partnership or an individual. Please identify the legal entity option relevant to you. Tick one:

a. Individual b. Partnership c. Company 2. INDIVIDUAL TUTOR CONTACT DETAILS Complete this section if you are entering into an agreement as an individual tutor, then proceed to Section 4. Name of Individual:

     

Phone Business Hours: Mobile: Address:

     

     

Phone After Hours: Email Address:

     

     

     

.

This program is funded by the Australian Government through the Department of Education, Employment and Workplace Relations.

-1-

3. COMPANY/PARTNERSHIP CONTACT DETAILS Complete this section if you are entering into an agreement as an individual through a company or a partnership.      

Name of the legal entity:

     

ABN (if applicable):

Trading name (if applicable):

address      

Registered street (not a PO Box):

Postal address:

     

     

Contact details of company officers (if a company) Name:

     

Name:

     

Role:

     

Role:

     

Address:

     

Address:

     

Email:

     

Email:

     

Phone:

     

Phone:

     

Details of additional officers can be attached to this form 4. TEACHER QUALIFICATIONS AND EXPERIENCE Formal education qualifications:

Registering Authority:

     

Registration Number:

     

     

This program is funded by the Australian Government through the Department of Education, Employment and Workplace Relations.

-2-

If you are not a currently registered teacher you must supply the following information (not required if you are a currently registered teacher). You must be able to provide certified copies of academic results or other documentary evidence if requested. Relevant experience: Please provide details of relevant experience, e.g. Teacher Aide at ... Primary School for ... years.      

Working With Children check or Australian Federal Police check or relevant state equivalent: (see Tutor information document) Type: Date obtained:

AFP      

WWC Reference number (if known):

     

5. STATE AND AREAS YOU ARE PREPARED TO OFFER TUITION SERVICES: Please list all of the areas (suburbs, local government areas or geographic regions) in which you would be prepared to accept tuition work. You will usually only be offered tuition work in regions which you have listed.      

6. SPECIAL COMPETENCIES, SKILLS OR EXPERIENCE: State your preference for reading/writing or numeracy tuition, and at which year levels. Also list any qualifications or experience in working with students with special needs or students with culturally or linguistically diverse backgrounds.      

7. RELEVANT MEMBERSHIPS OR AFFILIATIONS: e.g. Membership of the Australian Tutoring Association or other relevant associations and date of commencement.      

8. REFEREES: Provide the details of two persons qualified to provide a confidential professional reference over the phone, if required by the PTC. Testimonials or written references are not acceptable.

Name: Address:

           

Daytime telephone or mobile phone number: Email:

     

Name:

     

Address:

     

Daytime telephone or mobile phone number: Email: