Application to License an Agent

Application to License an Agent

A $100 fee will be assessed for each licensed agent.
Payment Received

YesNo
Name of Institution *
Agent(s) are representing the following:*

Chapter 1 Non-Degree Granting Proprietary SchoolChapter 18 Non-Religious K-12 SchoolChapter 30 Degree Granting Institution
Date

MonthDayYear
Date
Name of Administrator*

First NameLast 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

CityState / Province

Postal / Zip Code
Registration Period (July 1 through June 30 annually)*

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.*

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

CheckACH TransferCredit Card
Check Number
Date of ACH Transfer

MonthDayYear
Date
Credit Card Processing
Signature

Clear
Should be Empty:

Agent Information