Application to License an Agent

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) *

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
Signature

Clear
Should be Empty:

Agent Information