AGENT APPLICATION

1. AGENT INFO

Basic Info

* Agency Name :

* Agency Website :

* General Email Address :

* Establishment Date :

Business License Number :

* Phone (Main) :

(eg. +1 604 998-1000)

Mailing Address

* Street :

* City :

Province/State/Region :

* Country :

* Postal Code :

Profile

* Programs primarily represented :

* List of countries representing :

* Where did you hear about Bodwell? :

* How would you promote Bodwell programs? :

How many students did you send to Canada last year? And for which program? :

2. CONTACT INFO

Main Contact Person

* Position Title :

* Title :

* Sex :

* First Name :

* Last Name :

* First Language :

Second Language :

* Nationality :

* Email Address :

* Phone :

(eg. +1 604 998-1000)

Director or President

Check if same as main contact

* Position Title :

* Title :

* Sex :

* First Name :

* Last Name :

* First Language :

Second Language :

* Nationality :

* Email Address :

* Phone :

(eg. +1 604 998-1000)

3. REFERENCE INFO

Institution #1

Institution Name :

Position Title :

Title :

First Name :

Last Name :

Sex :

First Language :

Email Address :

Phone :

(eg. +1 604 998-1000)

Street :

City :

Province/State/Region :

Country :

Postal Code :

Institution #2

Institution Name :

Position Title :

Title :

First Name :

Last Name :

Sex :

First Language :

Email Address :

Phone :

(eg. +1 604 998-1000)

Street :

City :

Province/State/Region :

Country :

Postal Code :

4. ATTACH FILES

5. COMMENTS

Any comments to leave? :