Agent Request

Pittsburg State University

Instructions:

Complete this application if your agency is interested in becoming an authorized representative for Pittsburg State University.
Send a copy of your business registration/license to iss@pittstate.edu once you have completed the form.
The review process could take 4-6 weeks to complete.
You will be notified of the status of your agent application at the end of the review process.
Questions can be directed to iss@pittstate.edu.

Name*

First Name

Last Name

Title/Position*

Agency Name*

Agency Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Work Phone*

Email*

Website URL

If your agency has Social Media pages, please link them here

What countries do you recruit from?*

How long has your agency been in existence?*

How many students did your agency send to the United States in the last year?*

What programs are you interested in representing?*

Intensive English Program Undergraduate Programs Graduate Programs

What majors are your students most interested in?

Is your agency affiliated with AIRC, ICEF, NAFSA or other industry affiliations?*

Yes No

Please list

Please provide two professional references.

Reference 1

First Name

Last Name

Title/Position

Institution

Reference 2

First Name

Last Name

Title/Position

Institution

Please provide any additional information that might be useful in our decision-making process.

Comments