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* MANDATORY FIELDS

FIRST NAME *	LAST NAME *
AGENCY NAME *	POSITION IN AGENCY
NUMBER OF FULL TIME EMPLOYEES	NUMBER OF PART TIME EMPLOYEES
APPROXIMATE ANNUAL GROSS SALES VOLUME (STRICTLY CONFIDENTIAL)	CURRENT CONSORTIA (IF ANY)
CURRENT GDS	ADDRESS
CITY *	PROVINCE *
POSTAL CODE	COUNTRY
EMAIL *	VERIFY EMAIL ADDRESS *
HOME PHONE	AGENCY PHONE
FAX	BEST TIME TO CONTACT YOU
HOW DID YOU HEAR ABOUT US *	IF OTHER
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Host Agency Solutions Head Office
David Wass & Leah Smith
2627 Portage Avenue, Winnipeg, Manitoba R3J 0P7, 1-204-934-8809

Regional Offices
Christal Bauer Western Canada Regional Manager
4045 - 200th Street, Langley BC V3A 1K8, BC Registration 28159

Penny Martin Eastern Canada Regional Manager
6 Airport Road, Suite 155, Suite 400, Mississauga, Ontario, L4V 1R9, Ontario Registration 01576226

845 Broad Street, Regina, Saskatchewan, S4R 8G9

Host Agency Solutions | Winnipeg, Manitoba, Canada | 1-866-904-4454