Application to License an Agent
A $100 fee will be assessed for each licensed agent.
Payment Received
Yes
No
Check Number or ACH Date
Payment Amount
Name of Institution
*
Agent(s) are representing the following:
*
Chapter 1 Non-Degree Granting Proprietary School
Chapter 18 Non-Religious K-12 School
Chapter 30 Degree Granting Institution
Date
-
Month
-
Day
Year
Date
Name of Administrator
*
First Name
Last Name
Email
*
example@example.com
Administrator Phone Number
*
Please enter a valid phone number.
Mailing address where agent cards should be sent
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Registration Period (July 1 through June 30 annually)
*
Please Select
2021-2022
2022-2023
2023-2024
2024-2025
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Agent Information
By accepting the terms, the institution agrees the the qualifications and personal data of the applicant have been vetted and believes that he/she will represent the institution as pledged.
*
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Payment Information
A $100 fee is required for each application agent. Checks should be sent to: Wyoming Department of Education Attn: Elaine Marces 122 W. 25th St. Suite E200 Cheyenne, WY 82002
Number of agents being registered today
*
Fee per agent
Total Amount Due
Method of Payment
Check
ACH Transfer
Credit Card
Check Number
Date of ACH Transfer
-
Month
-
Day
Year
Date
Credit Card Processing
Signature
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