Change of Agent Form

Change of Agent Form
1. Applicant Details (you must complete the required details)
Full Name:
HIT Student ID:
Date of Birth:

MonthDayYear
Date
Address:
Mobile:
Format: (000) 000-0000.
Email:
example@example.com
Course Name:
2. Previous Agent Details
Agent Name:
Agent Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
3. New Agent Details
Agent Name:
Contact Person:
Position Title:
Agent Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Signature:
Date:

MonthDayYear
Date
4. Reasons for Change
Please Provide a reason for the change of Agent (Supporting documents are required where applicable)
5. Student Declaration
Student Signature:
Date:

MonthDayYear
Date
Should be Empty: