956 (Design date 03/14) - Page 5
© COMMONWEALTH OF AUSTRALIA, 2014Organisation name (if applicable)
Office hours Telephone numbers
Mobile/cell
Migration Agent Registration Number (MARN)If applicable:
Offshore Agent ID Number
22Provide
at least one  of the following numbers
DIBP Request ID number (RID)DIBP Transaction Reference
Number (TRN)
Family name Full name (If the client is an organisation, provide the name of the contact person)  Given names
21Client’s details
Date of birth
Organisation name (if applicable)
Part B – Ending appointment
Family name Given names
20Migration agent/exempt person’s details
Part C – Declarations
2324Declaration by migration agent/exempt person
Declaration by client
Tick one onlytruncated form
Tick one only
Appointment  – I declare that I have appointed the migration agent/exempt person named in Part A of this form to provide assistance with matters as indicated on this form.
Appointment  – I declare that I have been appointed by the client named in Part A of this form as a migration agent/exempt person and that I will act on the client’s behalf as permitted by law.Ending appointment  – I declare that the migration agent/exempt person named in Part B is no longer acting on my behalf.Ending appointment  – I declare that I am no longer acting on behalf of the client named in Part B and I have advised the client accordingly.
Signature of migration agent/exempt person
Date
Signature of client
Date

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