Qualification Application for CCC Export Programs

CCC's Facility Guarantee Program (FGP)

Qualification Application for CCC Export Programs rev 05 20 2016

CCC's Facility Guarantee Program (FGP)

OMB: 0551-0032

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Paperwork Reduction Act Submission OMB #0551-0032

Expiration Date: xx/xx/xxxx

Qualification Application for CCC Export Credit Guarantee Programs

Top of Form

Shape1 Shape2 Shape3 Fields marked with an asterisk (*) are required

Program Applying For:

* Please check all that apply:

Shape4

Applying for the CCC GSM-102 Export Credit Guarantee Program in accordance with 7 C.F.R. Section 1493.30, eligibility criteria for participation.


Shape5

Applying for the CCC Facility Guarantee Program (FGP) in accordance with 7 C.F.R. Section 1493.220, eligibility criteria for participation.


1. Name and Address of Applicant's U.S. Office

*Company Name:

Shape6

*Street Address:

Shape7

P.O. Box:

Shape8

*City:

Shape9

State:

Shape10 Shape11



*Zip Code:
(Postal Code)

Shape12 - Shape13





*Telephone:

###-###-####
Shape14

Fax:

###-###-####
Shape15

*E-Mail:

Shape16

*Contact Name:

Shape17

Select One:

Shape18 Business       Shape19 Private Residence




* Please check that which applies:



            Shape20 U.S. Domestic Corporation     Shape21 Foreign Corporation     Shape22 Other Foreign Entity






2. Name and Address of Applicant's Headquarters Office (to be completed only if different from above)

* Company Name:

Shape23

* Street Address:

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P.O. Box:

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* City:

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State:

Shape27 Shape28



Zip Code:
 (Postal Code):

Shape29 - Shape30





* Country Name:

Shape31 Shape32

* Telephone:

##########
Shape33

Fax:

##########
Shape34









  1. Name and Address of U.S. Agent for the Service of Process (only to be completed if Exporter has no U.S. office)

    *Name:

    Shape35

    *Street

    Address:

    Shape36

    P.O. Box:

    Shape37

    *City:

    Shape38

    State:

    Shape39 Shape40



    *Zip Code:
    (Postal Code)

    Shape41 - Shape42





    *Telephone:

    ###-###-####
    Shape43

    Fax:

    ###-###-####
    Shape44

    *E-Mail:

    Shape45

    *Contact Name:

    Shape46

    Select One:

    Shape47 Business       Shape48 Private Residence

  2. Applicant's Legal Form of Doing Business

Applicant's legal form of doing business:

* Type of Business:

Shape49

5. Country of Incorporation Where Legally Registered (please select a U.S. State if country is the United States)

*Country Name:

Shape50 Shape51

U.S. State: Shape52 Shape53

  1. Required Applicant Information

    Business Web Site:

    Shape54

    * Dun & Bradstreet (DUNS)
    Number (Site specific):

    ##-###-####
    Shape55

    * Tax ID Number:

    ##-#######
    Shape56

    Is the applicant a "small or medium
    enterprise" (SME)? An SME is an
    enterprise, as described by the
    U.S. Census Bureau, with 500
    or fewer employees. For the U.S.
    Census Bureau's definition of an
    enterprise, visit their web site:

    Shape57 No Shape58 Yes



    List any related companies
    (i.e. affiliates, subsidiaries,
    or companies otherwise related
    through common ownership)
    currently qualified to participate
    in CCC export programs:

    Shape59


    Nature of applicant's business
    (i.e. agricultural producer, trader, consulting firm, etc.):






    Shape60

    FGP Applicants:

    Explanation of the applicant's
    experience/history with agricultural
    commodities, goods or services for
    the preceding three years including a

    description of the commodities or goods or services:

    Shape61

    GSM-102 Applicants:

    Explanation of the applicant's experience/history with

    exporting U.S. agricultural

    commodities, including the number

    of years involved in exporting, types of
    products exported and destination of

    exports for the preceding three years:

    Shape62





  2. Certification Statements

* Please make one of the following certifications:

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"I certify that the above named applicant has not participated in any U.S. Government programs, contracts or agreements during the past three years."

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"I certify that the above named applicant has participated in U.S. Government programs, contracts or agreements during the past three years."

* Please describe prior participation:
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* Applicant must certify to the following statement(s) by selecting the block(s) below:

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All Section 1493.60(a) certifications are being made in this document. (GSM-102)


Shape67

All Section 1493.250(a) certifications are being made in this document. (GSM-FGP)




  1. * Name and Position of Individual Submitting Form:
    Shape68    Shape69
    (This form must be submitted by an “officer” of the Company making application. Pease also fax a copy of your Articles of Incorporation to (202) 720-2949)

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorJonathan.Doster
File Modified0000-00-00
File Created2021-01-23

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