2025 - Change of Agent Nomination Form

Change of Agent Nomination Form
By Completing the Change of Agent Nomination Form, you are officially advising Glen Institute of your intent to nominate an agent or new agent to represent you in your application to study at Glen Institute.
Section 1 - Student Details
Student Name
Student ID
Email Address
example@example.com
Contact Phone Number
Section 2 - Agent Details
Current Agent Company Name:
Contact Person:
Phone Number
Please enter a valid phone number.
Nominated Agent Company Name:
Contact Person:
Phone Number
Please enter a valid phone number.
Reason for Changing Agent:

Agent representative provided incorrect or misleading informationAgent representative is not responsive to my requestsOther (Please explain)
Student Declaration
Student Signature:

Clear
Date:

DayMonthYear
Date
For Office Use Only
Agreement signed with the new agent

YesNo
Agreement signed with the new agent

YesNo
Outgoing Agent communicated about the change and dues cleared/communicated

YesNo
Signature

Clear
Date:

DayMonthYear
Date
Should be Empty:

Change of Agent Nomination Form