Your name:

Mailing address: (including zip 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:

State: in which you presently reside Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

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: