AGENT ESL APPLICATION

Name of Agency:

Name of Representative:

Address:

City:

Province/Postal Code:

Country:

Phone Number:

Fax Number:

E-mail Address:


Student Information
Student - First Name:

Student - Last Name:

Student - Gender:

Student - Date of Birth:

Student - Native Language:

Student - Country of Nationality:

Student - E-mail Address:


Canada Address and Contact Information
Canada - Street Address:

Canada - City, Province, Postal Code :

Canada - Phone Number:

Canada - Fax Number:


Country Address and Contact Information
Home - Street Address:

Home - City, Province, Postal Code :

Home - Country:

Home - Phone Number:

Home - Fax Number:


Course Information
Desired Length of Study at London Language Institute:
Desired Start Date:
English Level:
Accommodation:
Medical Insurance:
Airport Pickup:
If required, Required from
arrival date:
to
departure date:
Additional Comments:


Payment Information

A CAD$100 non-refundable deposit is required to process your application and issue a letter of acceptance. Click “Submit now!” to submit your application. You will then be redirected to our secured online payment page to make your $100 deposit.

* London Language Institute will be in contact with you within 3 business days.
** Please contact our office if you require an original letter of acceptance couriered to you.
*** Fees for this service vary and we can provide you with this service if required.