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Agency/Business Name*

Main Point of Contact Name*

Owner of Company Name

Complete Address*

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Phone Number*

Email Address*

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Website

Number of Years in Business*

Country (ies) City (ies) represented*

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Number of Staff*

What can you tell us about your market in general? What makes your market unique?*

Have you and or your staff been through any formal training (workshops/seminars/conferences) related to working as an agent?*

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Does your Agency represent other institutions/organizations in Canada?*

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Please list the services your company currently provides.*

Do you have any affiliations with regulatory bodies?*

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Regulatory body name

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Which of our services are you most intrested in?*

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