Global Network Associates is committed to high quality of service and integrity and believe that we can achieve a high efficiency and success rate without compromise.

If you share the same philosophy and would like additional information on how to become our business associate, please contact us.

• CONFIDENTIAL REPLY FORM - INDEPENDENT REPRESENTATIVE •

First Name:
Family Name:
Company Name: (if replying on behalf of a Corporation)
Principle Mailing Address:
Company:
Home:
Office Telephone Number 1:
Office Telephone Number 2:
Office Fax Number 3:

Due to the difference in time zones, it may sometimes be necessary to call at home. We will, of course, make these calls at your home only when necessary. If acceptable, please list your

Home Number:
Number Fax:
Cellular/Mobile Phone Number:
Pager Number:
E-mail Address 1:
E-mail Address 2:

In the event we are unable to reach you at any time, is there somebody else we can contact? If yes, please provide the following details:

First Name:
Family Name:
Telephone Number:
Fax Number:
E-mail Address:
Are you currently employed?	Yes No
(if yes, please indicate your current occupation)

Have you ever represented a firm specializing in Immigration?	Yes No
(if yes, please provide details)

Please briefly describe your office / working conditions

In which Countries and/ or Cities would you like to represent Global Network Associates
1.
2.
Briefly describe
(1) Your reasons for selecting this line of business

(2) Your reasons for selecting Global Network Associates

Additional Comments