Application for Consideration as an Education Agent

Company Background
Please provide evidence of local business registration requirements.*

Cancelof
Has the company or any individual within the company ever been involved in past, pending, threatened, or potential litigation, arbitration, administrative actions, or other disputes?*

NoYes
Upload Business Profile and Organizational Chart

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Key Business Activities*
Year Established*
Years as an education agent*
Number of staff*
Partnerships with other agencies (list)*
Associations with other relevant organizations (list)*
Do you currently represent, or have you in the past represented other medical schools?*

NoYes
Please indicate the geographical territory you will service*
Provide a description of your target market, trends, demands, etc.*
Number of students sent abroad each year*
Proposed number of students sent to us in the next year*
Services provided to students*
Please provide details of any fees charged to students*
Educational References (x2)*
Signature*

Clear
Do you currently represent any medical schools in our region?*

NoYes
Please provide the names of the medical school
Declaration
This form serves only as my interest to represent the University of Health Sciences Antigua as an educational agent. I understand that this document does not serve as a contract.
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Company Profile