Distributor/Customer Information Form

Term 2016 - 2017  (must be filled out completely and printed on company letterhead in order to be processed)

Date:
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Name of entity:*
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Address of entity’s principal place of business or headquarters:*
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Years in Business:*
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Phone:*
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Website address:
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Main email address:*
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Country Locations of Entity’s offices worldwide:*
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List worldwide country locations or places where you ship the goods (Final Destination).:
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Names and titles of entity’s ultimate parent company and individuals with controlling ownership:
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Names of entity’s subsidiaries if any:
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Names of Entity’s Directors, Senior Management, CFO/CEO, President, Treasurer, General Managers:
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Contact person, phone and fax of Three Business Referenes (e.g. Other U.S. Companies):
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Record of any Penalties or Proceeding Under U.S Export or Sanction Laws:
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Any Other Relevant Information:
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Signature of person who provided the Information
Name:
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Date:
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Title:
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