Qualification Application for CCC Export Guarantee Progr

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Qualification Application for CCC Export Credit Guarantee Programs

Fields marked with an asterisk (*) are required

Program Applying For:

* Please check all that apply:
	Applying for the CCC GSM-102 Export Credit Guarantee Program and Facility Guarantee Program in accordance with 7 C.F.R. Section 1493.30 and 1493.420, eligibility criteria for participation.
	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:
   * Street Address:				P.O. Box:
   * City:		* State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Col. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
   * Zip (Postal) Code:	-
   * Telephone:	###-###-####	Fax:	###-###-####
   * E-Mail:
   * Contact Name:
   * Select One:	Business       Private Residence



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

   
   

   Company Name:
   Street Address:				P.O. Box:
   City:		State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Col. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
   Zip Code:   (Postal Code):	-
   Country Name:	Algeria Angola Antigua Argentina Armenia Aruba Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bolivia Botswana Brazil Burkina Faso Burundi Cameroon Canada Canada Canary Islands (Spain) Cape Verde Cayman Islands Central African Republic Chad Chile China (Mainland) Colombia Congo Cote D'Ivoire Cyprus Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Faroe Islands France French Guiana French Polynesia Gabon Gambia Georgia Ghana Greenland Grenada Guadeloupe Guatemala Guinea Guinea-Bisseau Guyana Haiti Honduras Hong Kong India Indonesia Ireland Israel Ivory Coast Jamaica Jordan Kazakstan Kenya Korea Kuwait Kyrgyzstan Lebanon Lesotho Madagascar Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mexico Moldova Morocco Mozambique Namibia Netherlands Antilles New Caledonia Nicaragua Niger Nigeria Oman Oman & Muscat Pakistan Panama Paraguay Persian Gulf Peru Philippines Qatar Reunion Russia Rwanda Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Somalia South Africa South Korea Sri Lanka St. Lucia St. Vincent Sudan Suriname Swaziland Switzerland Taiwan Tajikistan Tanzania Thailand The Netherlands The Republic of Korea The Republic of Yemen Togo Trinidad and Tobago Tunisia Turkey Turkmenistan USSR Uganda Ukraine United Arab Emirates United Kingdom United States Uzbekistan Venezuela Vietnam Yemen Yugoslavia Zaire Zambia Zimbabwe
   Telephone:	###-###-#### (if United States)	Fax:	###-###-#### (if United States)

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

   
   

   Name:
   Street Address:				P.O. Box:
   City:		State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Col. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
   Zip Code: (Postal Code)	-
   Telephone:	###-###-####	Fax:	###-###-####
   E-Mail:
   Contact Name:
   Select One:	Business       Private Residence



4. Applicant's Legal Form of Doing Business

   
   

   * Type of Business:	Sole Proprietorship Partnership DBA Corporation Foreign Corporation Individual LLC Other



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

   
   

   * Country Name:

   Algeria Angola Antigua Argentina Armenia Aruba Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bolivia Botswana Brazil Burkina Faso Burundi Cameroon Canada Canada Canary Islands (Spain) Cape Verde Cayman Islands Central African Republic Chad Chile China (Mainland) Colombia Congo Cote D'Ivoire Cyprus Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Faroe Islands France French Guiana French Polynesia Gabon Gambia Georgia Ghana Greenland Grenada Guadeloupe Guatemala Guinea Guinea-Bisseau Guyana Haiti Honduras Hong Kong India Indonesia Ireland Israel Ivory Coast Jamaica Jordan Kazakstan Kenya Korea Kuwait Kyrgyzstan Lebanon Lesotho Madagascar Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mexico Moldova Morocco Mozambique Namibia Netherlands Antilles New Caledonia Nicaragua Niger Nigeria Oman Oman & Muscat Pakistan Panama Paraguay Persian Gulf Peru Philippines Qatar Reunion Russia Rwanda Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Somalia South Africa South Korea Sri Lanka St. Lucia St. Vincent Sudan Suriname Swaziland Switzerland Taiwan Tajikistan Tanzania Thailand The Netherlands The Republic of Korea The Republic of Yemen Togo Trinidad and Tobago Tunisia Turkey Turkmenistan USSR Uganda Ukraine United Arab Emirates United Kingdom United States Uzbekistan Venezuela Vietnam Yemen Yugoslavia Zaire Zambia Zimbabwe

   U.S. State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming



6. Required Exporter Information

   
   

   Business Web Site:
   * Dun & Bradstreet (DUNS) Number (Site specific):	##-###-####
   * Tax ID Number:	##-#######
   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:	No Yes
   List any related companies (i.e. affiliates, subsidiaries, or companies otherwise related through common ownership) currently qualified to participate in CCC export programs:
   Nature of applicant's business (i.e. agricultural producer, commodity trader, consulting firm, etc.):
   FGP Applicants: Explanation of the applicant's experience/history with agricultural commodities or products for the preceding three years, including a description of the commodities:
   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:



7. Certification Statements

   
   

   * Please make one of the following certifications:
   	"I certify that the above named applicant has not participated in any U.S. Government programs, contracts or agreements during the past three years."
   	"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:
   * Applicant must certify to the following statement(s) by selecting the block(s) below:
   	All Section 1493.250(a) certifications are being made in this document. (GSM-FGP)
   	All Section 1493.60(a) certifications are being made in this document. (GSM-102)

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

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0551-0004. The time required to complete this 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.

 

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