Sending Agent Application

Basic Company Details

Company's Legal Name

Doing Business As (if applicable):

Business Phone

Business Website

Full Business Address (Street/City/Country/Postal Code)

Years in Business

Type of Business

Emergency telephone number available to business partners and participants:

Main Company Contact Information

Name

Professional Title

Phone Number

E-Mail Address

Additional Company Contact Details

Name

Professional Title

Phone Number

E-Mail Address

Owner/Officer Information

Name

Professional Title

Phone Number

E-Mail Address

Owner/Officer #2 Information

Name

Professional Title

Phone Number

E-Mail Address

Affiliation and Experience

List all organizations you are affiliated with (nationally and internationally), including companies you recruit au pairs for. (Include each companies name, country, and type of relationship/affiliation):

How many au pairs or exchange participants do you provide today? (Include # of participants, to which country and through which exchange program)

Have you previously been affiliated with a U.S. Au Pair Program?
YesNo

If "yes", please give details (which agency, number of au pairs, year, etc.):
[text area* Details]

Volume

Areas/countries you wish to recruit au pairs from:

List the estimated number of au pair applications you hope to be send each year:

List all fees and fee amounts you plan to charge from the au pair applicants:

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