Name of Company or Organization * Contact Information Name of Primary Contact * First Last * Last Contact Email Address * Website address of Organization * Address * Address Line 2 City * Country * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Congo (DRC) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe State AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Postal Code Office Phone Number include country code and city code Mobile Phone Number of Contact * Skype Name/Address Please enter your username for Skype. Company Information Primary Activities and Services of Your Company/Organization * College Student Placement Exchange Student Placement High School Student Placement Visa Preparation Services Travel Agency ESL Classes Test Preparation Summer Camps Other (Please Describe Below) Check all that Apply. Other Activities and Services Approximately how many students does your company place in the U.S. each year? * Primary countries from which you recruit students Has your company placed high school students in the US? * Yes No Approximately how many high school students have you placed in the U.S. in the past year? References Please provide 3 references where you have placed students Reference Name * Reference Phone Number * Reference Email Address * Reference Name * Reference Phone Number * Reference Email Address * Reference Name * Reference Phone Number * Reference Email Address * Statement and Signature I have reviewed The GLEE Network's website and understand the principles of the GLEE Network and it's affiliated schools. I wish to receive an Agent agreement. Check the box to indicate your acknowledgement of the statement above. * I agree Date *
