Agent Application

1) Official Agency Name:*

2) Postal Mailing Address:

Line 1*

Line 2

City:*

Province/State

Postal Code

Country*

3) Is this your Main Office or a Branch Location?*

Main Office

Branch Location

If you have branch offices, please complete this form for each branch office that might be sending applications to us. You may list different contact information for each location.

4) Telephone:*(country code + city code + local number)

5) Preferred Email Address*

6) Secondary Email Address:

7) When was your agency established?*

8) What countries do you recruit students from?*

9) Do you charge a fee for helping students?*

10) Please write a short paragraph (less than 500 words) to briefly introduce your agency:

11) Is your agency:*

12) How many students at each level did your company send to the U.S. last year?

a) ESL:

b) UG:

c) GR:

d) Exchange students:

13) How many applications at each level do you anticipate sending to Wichita State University next year?

a) ESL:

b) UG:

c) GR

d) Exchange students:

14) Which are the best selling points of Wichita State University in your market?

15) Are you currently an agent for Wichita State University(or ever been an agent for us in the past)?*

Yes

No

I am not sure

16) our agency's industry membership or recognition:

AIRC

ICEF

NAFSA

None

Others

17) your Website

18) Main contact person

a) Job title*

b) Prefix*(Mr, Ms, Mrs, Dr, etc)

c) First Name*

d) Last Name*

e) Title:*

f) Email Address:

g) Finance Email Address:

20) Please provide two references of U.S. institutions your agency is working with:

Reference #1

a) Contact Name

b) Institution:

c) Contact Email

Reference #2

a) Contact Name:

b) Institution:

c) Contact Email

21) Have you carefully read our Guidelines for Agents to get information about how much you will be paid for your services, our expectations for agents, and our Code of Conduct?

Have you read our Guidelines for Agents?*

Yes

No

22) In order to become one of our agents, you must agree to the following:

"I have read the Wichita State University Guidelines for Agents and I understand and agree that the Guidelines for Agents are specifically made part of this Application. I agree to abide by the Agent Code of Conduct and understand that Wichita State University may terminate its relationship with any agent or agency that the University determines, in its sole and complete discretion, has violated the code of conduct. I have also read and understand the conditions under which I or my agency would be paid for its services."

Do you agree above the statements?*

Yes, I understand and agree with the above statement

No, I do not agree.

23) Name of person electronically agreeing to the above statement:*

25) Name of Agency agreeing to the above statement:*

24)Date electronically signed:*(mm/dd/yyyy)

26) QuestionsIf any