SHMU Agent Application Form Template
SHMU Agent Application Form Template
Shahroud University of Medical Sciences (SHMU) Office of International Relations and Global Engagement
Introduction and Purpose
This form serves as the official application template for entities or individuals seeking to become authorized recruitment agents or representatives for Shahroud University of Medical Sciences (SHMU) and Shahroud Health and Medical University (SHMU) programs. All sections must be completed accurately and thoroughly. Incomplete applications will result in processing delays or rejection.
Section 1: Agency Details
Please provide comprehensive legal and operational details of your agency.
|
Field |
Requirement/Instruction |
Response Area |
|
1.1 Agency Legal Name |
The full, legally registered name of the business entity. |
……………………………….. |
|
1.2 Agency Trade Name |
The name under which the agency operates publicly (if different from Legal Name). |
……………………………………… |
|
1.3 Agency Registration/ License Number |
Official government-issued registration or license number (e.g., Company Registration Number). |
……………………………………… |
|
1.4 Country of Registration |
The jurisdiction where the agency is legally incorporated. |
…………………………………………. |
|
1.5 Agency Address (Physical Location) |
Primary operational street address. |
……………………………………. |
|
1.6 Agency Address (Mailing/Postal) |
Address for official correspondence (if different from Physical). |
…………………………………… |
|
1.7 Type of Business Entity |
Individual Consultant (Sole Proprietor), ( ) Partnership, ( ) Limited Liability Company (LLC), ( ) Corporation (Inc./PLC), ( ) Other (Specify): ______ |
…………………………….. |
|
1.8 Date of Establishment/ Founding |
The official date the agency commenced operations (DD/MM/YYYY). |
………………………………… |
|
1.9 Number of Active Recruitment Staff |
Total number of full-time and part-time staff actively involved in student recruitment and counseling activities. |
……………………………………… |
|
1.10 Countries of Operation (Primary Focus) |
List the top five countries where the agency actively recruits students. |
1. ____ 2. ___ 3. __ 4. __ 5. _____ |
Section 2: Contact Information and Key Personnel Provide details for the primary individual responsible for liaison with SHMU.
|
Field |
Requirement/Instruction |
Response Area |
|
2.1 Primary Contact Name |
Full name of the designated representative/director. |
……………………………….. |
|
2.2 Primary Contact Title |
Official title of the Primary Contact (e.g., CEO, Director of International Admissions). |
……………………………………… |
|
2.3 Primary Contact Direct Phone Number |
Include international dialing codes |
……………………………………… |
|
2.4 Primary Contact Email Address |
Professional email address for official communication. |
…………………………………………. |
|
2.5 Alternative Emergency Contact |
Name of a secondary contact person |
……………………………………. |
|
2.6 Alternative Emergency Phone/ Email |
Contact details for the secondary contact. |
…………………………………… |
Section 3: Student Recruitment & Service Scope
Quantify your agency's experience and detail the scope of services offered related to medical and health sciences education.
3.1 Recruitment History (SHMU Focus)
Please detail the number of students successfully placed/enrolled with SHMU in the specified periods. If the agency is new, provide realistic projections based on market research.
|
Period |
Number of Enrolled Students (Projected/Actual) |
Programs Targeted (e.g., Medicine, Dentistry, Allied Health) |
|
Past 1 Year |
……………………………… |
……………………………….. |
|
Past 2 Years |
……………………………………… |
……………………………………… |
|
Past 3 Years |
………………………………….. |
……………………………………… |
|
Total (Last 3 Years) |
…………………………………. |
…………………………………………. |
3.2 Institutional Representation Portfolio
List all other international higher education institutions (Universities, Colleges) that your agency currently represents or has represented in the last 12 months.
Institution Name Country Status (Current/Past)
______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________
3.3 Declaration of Service Fees and Commission Structure
SHMU mandates transparency regarding all financial arrangements between the agent and the student.
3.3.1 Student Service Fees:
Do you charge students a service/counseling fee for application assistance? ( ) Yes ( ) No.
If Yes, please describe the fee structure (e.g., Flat fee, percentage of tuition, hourly rate): ________________________
Maximum Fee Charged to a student for SUMS application: ______
(Specify Currency).
3.3.2 Institutional Commission Understanding:
We confirm that any commission structure agreed upon with SUMS/ SHMU will be clearly disclosed to the student, ensuring the student understands that the commission is paid by the institution, not directly extracted from their fee or tuition payment, unless explicitly agreed upon separately and transparently. (Check Box to Affirm): [ $ \square$ ]
Section 4: Compliance and Declarations (Ethical Framework Adherence)
By signing below, the applicant confirms adherence to all institutional standards and international best practices.
|
Declaration Item |
Confirmation Check |
Notes/ Reference if Applicable |
|
4.1 Ethical Adherence |
I confirm full agreement to adhere to the 'London Statement' Ethical Framework (or the most current equivalent ethical guidelines for international recruitment). |
……………………………….. |
|
4.2 Visa Fraud Prevention |
I declare that my agency has never been involved in facilitating or encouraging fraudulent visa applications or providing intentionally false documentation to support student visas. |
……………………………………… |
|
4.3 Information Accuracy |
I confirm that all information provided in Sections 1, 2, and 3 of this application form is accurate, complete, and verifiable upon request. |
……………………………………… |
|
4.4 Data Protection & Confidentiality |
I confirm adherence to local data protection laws (or GDPR, if applicable to student data) regarding the protection and non-disclosure of student personal and academic information. |
…………………………………………. |
|
4.5 Conflict of Interest |
I declare that there are no undisclosed conflicts of interest between this agency and any current SUMS/SHMU admissions staff or decision-makers |
…………………………………………. |
Section 5: Required Attachments (Checklist for Submission)
The following documents must accompany this application form for it to be considered complete.
Please check $(\checkmark)$ once each document has been attached:
|
Document |
Status |
Notes |
|
5.1 Business Registration Documents |
[ $ \square$ ] |
Certified copy of legal formation papers |
|
5.2 Agent/Consultant Training Certificates |
[ $ \square$ ] |
Certificates such as ICEF, MARP, or other recognized professional qualifications |
|
5.3 Signed Declaration of Ethical Adherence |
$ \square$ ] |
A separate document confirming adherence to the specific SUMS/SHMU Code of Conduct. |
|
5.4 Proof of Business Address |
$ \square$ ] |
A recent utility bill or official bank statement showing the registered physical address (dated within the last 90 days). |
|
5.5 Principal’s CV/ Resume |
$ \square$ ] |
Curriculum Vitae of the Primary Contact listed in Section 2. |
Section 6: Applicant Signature & Verification
This section formalizes the application submission and acknowledges understanding of the terms outlined.
Applicant Entity Name: __________
Authorized Signatory Name (Print): __________
Authorized Signatory Title: __________
Signature: __________
Date of Submission: (DD/MM/YYYY) _____
Institutional Reviewer Use Only
Date Received by SHMU: _____
Reviewer ID: _____
Document Completeness Check: ( ) Complete ( ) Requires Additional Information (Specify Deficiency: ____________)
Preliminary Assessment: ( ) Favorable ( ) Unfavorable ( ) Pending Site Visit/ Further Vetting
Institutional Reviewer Comments:
…………………………………………..