New Agent Application Form

Company Name

Registered Company Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Contact Telephone

Email

Website Address

Date of First Agreement with Primetake (If Applicable)

Your Name

First

Last

Your Title

Please attach evidence of legal status (for example: Certificate of Incorporation, Chamber of Commerce registration, relevant Trade Body membership):

Click or drag files to this area to upload. You can upload up to 5 files.

Excepted Formats: .pdf, .doc, .docx, .xls | Max File Size: 20mb (for each file)

Legal form (company, partnership etc):

Date of Incorporation

Issued Share Capital Value

Add Each Shareholder (with percentage ownership):

Note: This is not a requirement and will not affect your application.

Shareholder Name

%

Please attach a copy of your most recent audited financial report and accounts:

Click or drag files to this area to upload. You can upload up to 5 files.

Excepted Formats: .pdf, .doc, .docx, .xls | Max File Size: 20mb (for each file)

Are any current government employees, agents, elected representatives or judiciary officials among the company’s shareholders, or related closely or otherwise connected to them?

Yes
No

Please explain:

Applicants Directors

Note: This is not a requirement and will not affect your application.

Name & Title of Director

(if applicable)

Business History

Max Wordcount: 500 words

Please attach resumes or CV’s if available:

Click or drag files to this area to upload. You can upload up to 5 files.

Excepted Formats: .pdf, .doc, .docx, .xls | Max File Size: 20mb (for each file)

Is any director or employee of your company a member of a governmental organisation of a political party or seeking election to a public office?

Yes
No

Please Explain

Have the company or its associated organisations or any of its shareholders, directors or employees, been accused, prosecuted and/or convicted in the present time or in the past of criminal offence?

Yes
No

Please Explain

Does a director or key employee of the company receive any official payment from the government?

Yes
No

Please Explain

Please describe the company’s areas of operation and expertise:

Please indicate the number of employees at your company:

Please list the company’s current clients:

Client

e.g. Primetake

Country

e.g. United Kingdom

Industry

e.g. Defence

Please provide three independent current business references, preferably regionally based, whom you have been representing for more than two years:

Referee Company Name

Referee Name

First

Last

Referee Job Title

Phone

Email

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Website Address

Signature

Clear Signature

Signees Name

First

Last

Signees Title

Date

Confirm You Are Human

What is 7+4?