Fill and Sign the International Distributor Candidate Questionnaire Form

5.14 International Distributor Candidate Questionnaire[COMPANY NAME] QUESTIONNAIRE FOR CANDIDATE-DISTRIBUTORS NOTE: RECEIVING, COMPLETING OR RETURNING THIS FORM TO [COMPANY NAME] DOES NOT ENTITLE THE CANDIDATE-DISTRIBUTOR TO SELECTION AS A DISTRIBUTOR AND DOES NOT OBLIGATE [COMPANY NAME] TO ENTER INTO ANY CONTRACT OR OTHER BUSINESS ARRANGEMENT WITH THE CANDIDATE-DISTRIBUTOR. Company name: Domicile country: Company address: Contact name: Telephone:Fax: Company directors (attach additional sheets, as necessary): Name Address Occupation Nationality ___________ ____________ ____________ ____________ Company officers (attach additional sheets, as necessary): Name Address Occupation Nationality___________ ____________ ____________ ____________ Company shareholders (attach additional sheets, as necessary): Name Address Occupation Nationality or country of formation ___________ ____________ ____________ _____________________ Are any of the company's directors, officers or shareholders affiliated with or related to any government officials, agencies or entities? _ Yes _ No If "yes," please explain (attach additional sheets, as necessary): Name Relationship to Company Relationship to government officials, agencies or entities ___________ _________________________ _____________________ Registration of Company: Commercial registration, business license or other registration number: Date of receipt: Products proposed to be distributed: Territories proposed to be covered: Length of time in present business: Other lines of business: Type of Business Length Of Time in That Business _____________________________ ______________________________Revenues of the Company for the past three annual accounting periods: Period Revenues _______________________ __________________ Please attach a copy of the latest published accounts of the Company. Employees: Number of Engineering/Technical employees: Number of Sales/Marketing employees: Number of other employees (specify general function): Facilities: Type of Facility (headquarters, office, factory, showroom, etc.)Location Number of employees Describe past and current distributorship relationships involving the territories covered by this questionnaire, including a list of related manufacturers and products (attach additional sheets as necessary): Name of Manufacturer or Other Company Products Type of Relationship (distributorship, license, joint venture, etc.) Dates of Relationship Decribe products developed and/or manufactured by the Company that are similar to, components of, or otherwise related to products covered by this questionnaire (attach additional sheets as necessary): Product Date of Development or First Manufacture by the Company Period of Sale How much annual revenue do you anticipate generating from the proposed distributorship?: _________________________ Describe your anticipated orders for products from [COMPANY NAME] below. NOTE THAT PROVIDING THIS INFORMATION DOES NOT OBLIGATE THE COMPANY TO MAKE ANY ORDERS, OR ANY LEVEL OF ORDERS FROM [COMPANY NAME]: Product Anticipated Units Anticipated Order Date Describe the Company's capability to provide marketing, sales and pre-purchase support: Describe the Company's capability to provide after-sales service and assistance: References (in each case, provide the name of the reference, the name of the Company's contact person at the reference, and the address and telephone number of the reference):Bank: Trade/Credit #1: Trade/Credit #2: Trade/Credit #3: Please provide any other information that is relevant to the proposed distributorship: [COMPANY NAME] is a U.S. corporation. U.S. law prohibits the offering, promising or giving, directly or indirectly, of anything of value to any government official, political candidate or employee thereof or to any third party while knowing that such item of value or any portion thereof may be offered, promised or given to such persons for the purpose of obtaining or retaining business. Moreover, [COMPANY NAME], as a matter of corporate policy, believes that it is imperative to be a good corporate citizen in each of the jurisdictions in which it does business and believes it is inconsistent with this policy to make any such improper inducements. Potential distributors will be required to confirm compliance with this policy. I hereby certify that, to the best of my knowledge, the above information is correct and complete. Signed:_______________________ Printed name:__________________ Title:_________________________ Date:__________________________