Form ITA-4136P U.S. Government Trade Event Information Requesst

FORM ITA-4136P OMB Control No. 0625-0238

Expiration Date: XX/XX/2013

U.S. GOVERNMENT TRADE EVENT INFORMATION REQUEST

The U.S. Government takes great pride in saluting the efforts and success of U.S. companies in developing overseas markets. To be considered for an event highlighting your company's project during a USG international trade event, please provide the following information and return it to the Advocacy Center at (202) 482-3508 (fax). If you have any questions, please call the Center at (202) 482-3896. Freedom of Information Act: Information submitted to the government may be subject to disclosure pursuant to the Freedom of Information Act. However, all confidential commercial information will be protected from disclosure to the extent permitted by law.

Event: ___________________________________________

Name of Company: ___________________________________________

Company Address: ___________________________________________

___________________________________________

Name of Contact Person: ___________________________________________

Telephone: Fax: ___________________

I. NATURE OF THE EVENT

A. Describe the event in which the USG official is to participate (e.g., site visit, announcement, ribbon-cutting, business agreement signing).

B. Identify all foreign and domestic entities involved, including ownership and control and role of each entity in the project.

Entity/Ownership Percent Ownership of this project

C. Briefly describe the role of the foreign business partner(s) (i.e. JV, etc.).

D. Please provide the name(s), address(es) and CEOs of foreign business partners

or buyers:

E. Please identify decision makers for this event.

Name Title Organization

F. What if any agreements/approvals have previously occurred in connection with this project?

G. What is your latest information on the status of this event?

H. What additional actions must occur before the event can materialize (e.g., financing needs to be secured, permits obtained, Ministry approval, etc.)?

I. List all signatories for any agreements to be witnessed:

Name Title Organization

J. Please describe the legal nature and impact of any document that will be signed.

II. INFORMATION ABOUT YOUR COMPANY

Please provide the following information about your company:

A. Full corporate name and headquarters address

B. If this company is a subsidiary, the parent company(ies) and any controlling individual(s)

C. Name of Chief Executive Officer (if CEO is not decision-maker, please identify appropriate company official)

D. Name, phone and fax of company’s in-country representative (if applicable)

III. ECONOMIC AND ENVIRONMENTAL IMPACT OF THE PROJECT OR TRANSACTION

Please provide the following information regarding the project or transaction:

A. Relevant industrial economic sector(s)

B. Overall economic value of the project or transaction

C. Value and detailed description of all projected U.S. export content

D. Principal U.S. subcontractors

E. States from which the projected U.S. export content will be sourced

F. Number of U.S. jobs created or retained

G. Environmental Impact

IV. DOCUMENTS REQUIRED

A. A copy of any agreement to be signed (this requirement cannot be waived). It will be treated as "business confidential".

B. A draft press release from your company announcing the event. Please include in the press release a description of any role of U.S. Government played in assisting to conclude this agreement (e.g., scheduled appointments, advocacy with foreign officials, trade events, trade negotiations, counseling, financing assistance, etc.).

C. Please provide specific points you would like the U.S. Government official to highlight regarding this event.

The undersigned, being so authorized, certifies on behalf of the Company that, to the best of my knowledge, the information provided herewith is complete and accurate, and that the Company is in compliance with applicable U.S. law including the Foreign Corrupt Practices Act.

____________________________________ ________________________________

Print Name Title

________________________________

Signature Date

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer, International Trade Administration,, Room 4001, U.S. Department of Commerce, Washington, D.C. 20230.

This information collection contains requirements subject to the Paperwork Reduction Act (PRA). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to penalty for failure to comply with, a collection of information subject to the requirements of the PRA, unless that collection of information displays a currently valid OMB control number.