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: ---MaleFemale 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: ---4812162024283236404448Other Desired Start Date:January 8, 2018February 5, 2018March 5, 2018April 2, 2018May 7, 2018June 4, 2018July 2, 2018July 30, 2018September 4, 2018October 1, 2018October 29, 2018November 26, 2018Other English Level: ---I don't knowBeginnerIntermediateAdvanced Accommodation: ---HomestayAccommodation Assistance Not Requested Medical Insurance: ---Medical Insurance Not RequestedMedical Insurance - 1 monthMedical Insurance - 2 monthsMedical Insurance - 3 monthsMedical Insurance - 4 monthsMedical Insurance - 5 monthsMedical Insurance - 6 monthsMedical Insurance - 7 monthsMedical Insurance - 8 monthsMedical Insurance - 9 monthsMedical Insurance - 10 monthsMedical Insurance - 11 monthsMedical Insurance - 12 months Airport Pickup: ---Airport Pickup Not RequestedPickup from Toronto AirportPickup from London Airport 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.