Agent ESL Application Agent Information 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 (dd/mm/yy): 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: Home Country Address and Contact Information (Note: A home country address is required for all international students.) 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 7, 2019February 4, 2019March 4, 2019April 1, 2019May 6, 2019June 3, 2019July 2, 2019July 29, 2019September 3, 2019September 30, 2019October 28, 2019November 25, 2019Other English Level: ---I don't knowBeginnerIntermediateAdvanced Accommodation: ---HomestayResidenceAccommodation Assistance Not Requested Medical Insurance: ---Student requires medical insurance for duration of studiesStudent has medical insurance, and will provide a copy prior to start date Airport Pickup: ---Airport Pickup Not RequestedPickup from Toronto AirportPickup from London Airport Please upload a copy of the student's passport (jpg,gif,pdf files accepted). If you are not able to upload the passport now, you will be requested to send a copy by email. . 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.