AGENT ONLINE APPLICATION FORM

Name (As per in your passport/ IC) *

Nationality *

Passport or IC Number *

E-Mail Address *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Gender *

Male
Female

Age *

How would you like us to contact you? *

What is your ID (WhatsApp/ WeChat/ LINE)

Phone Number *

How do you got to know about LEA ? *

Company Information

Name of Your Company

Company Registration Number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Website / URL

Which countries have you sent students to?

In Malaysia, which institute are you sending student to?

In a year, how many student have you sent to Malaysia?

Company Registration Documents

Click or drag a file to this area to upload.

Information for Commission Payout

Name of Bank

Single Line Text

Bank Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Name of the Account

Account Number

SWIFT Code

Consent & Acceptance

During LEA programmes, course components and events conducted online: I consent to the recording of my name, image, voice and any other personally identifiable information that may be shared during virtual sessions or meetings on Zoom or any other platforms (Meet, Zoom, Teams, Facebook etc.)*

I will abide by the policies, terms and conditions set by LEA governing enrolment, admission, refund and cancellation of fees.*

I will pay all fees due on the dates stipulated by LEA.*

I certify that the information provided in this form is complete and correct.*