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.Format: 0000 000 000.
Nominated Agent Company Name:
Contact Person:
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Reason for Changing Agent:

Other (Please explain)
Student Declaration
Student Signature:
Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
For Office Use Only
Agreement signed with the new agent
Outgoing Agent communicated about the change and dues cleared/communicated
Signature
Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty:

Change of Agent Nomination Form