Agent ESL Application

    Agent Information
    Name of Agency:

    Name of Representative:



    Province/Postal Code:


    Phone Number:

    Fax Number:

    E-mail Address:

    Student Information
    Student - First Name:

    Student - Last Name:

    Student - Gender:

    Student - Date of Birth (dd/mm/yy):

    Student - Native Language:

    Student - Country of Nationality:

    Student - E-mail Address:

    Do you require Immigration assistance?

    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:
    Will the student pay fees in full or on a monthly basis?
    Desired Start Date:
    English Level:
    Medical Insurance:
    Airport Pickup:
    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.