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    Business Structure


    Legal registration name of organisation

    Trading Name

    Organisation’s Legal Business Registration No

    Country / Region of Organisation’s Registration


    Name of Organisation's CEO

    Title

    First Name

    Last Name

    Street Address of the Organisation’s Principal Place of Business

    Address

    Address 2

    City/Town

    State/Province

    Zip/Postal Code

    Country / Region

    Street Address of the Organisation’s Postal Address

    (if different)

    Address

    Address 2


    City/Town

    State/Province

    Zip/Postal Code

    Country / Region


    Full Name and Title of Authorised Signatory

    Note: This should be a senior person in your organisation

    Title

    First Name

    Last Name

    Authorised Signatory Email

    Full Name and Title of Contact Person for Agency Agreements

    Title

    First Name

    Last Name

    Phone Number of Contact Person

    Email of Contact Person

    Head Office Location

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