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

DayMonthYear
Date
For Office Use Only
YesNo
YesNo
Signature
Date:

DayMonthYear
Date
Should be Empty:

Change of Agent Nomination Form