Your name:

Mailing address: (including postal code)

Telephone: Fax:

Date of birth: (month) January February March April May June July August September October November December (day) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 (year)

Email address:

Province: in which you presently reside Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon

City: (which you plan to represent)

Knowledge of the Internet:
(browsers, search engines, keyword searches, etc...) Select None Fair Good Very Good Excellent

Are you connected to the Internet? Yes No

Do you have access to a scanner? Yes No

Do you have access to a printer? Yes No

Do you have access to a digital camera? Yes No

Do you have access to Adobe Acrobat Reader? Yes No

Do you have a personal PayPal account? (optional) Yes No

Will this be a part-time of full-time venture? Select Part-time Full-time

If selected as a representative, how soon would you be available?

Resume (Paste your resume here)

Additional comments: