agency program     To find out more about the Intact IT Agency Program, please complete the following application. This application does not commit you or your company to joining the program but completion is required in order to receive any further information on the program. All information received by us will be held confidential. You will be contacted by an Intact Representative within two business days.     ----------------------------------------- Please complete the following information:  Highlighted fields are required    --------------------------------------------------------------    Contact Information         Company Name:     First Name:     Last Name:     Telephone:     Current Email:     City:     State/Province:   Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon    --------------------------------------------------------------    Additional Information   Best time to contact you: (check all that apply)      Days Evenings Weekends     Comments:       Attach Resume:

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