Exporter Application Form

OMB Number: 0551-0004
Expiration Date:

USDA

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United States Department of Agriculture

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Expon Cr�di1 Guaran1ee Program (GSM-10'2)

Programs

Qualification Application for CCC Export Credit Guarantee Prograr
Fields marked with an asterisk (') are required
Program Applying For:
• Please check all that apply:
D Applying for the CCC GSM-102 Export Credit Guarantee Program and Facility Guarantee Program in accordance with 7 C.F.R. Section 1493.30
1493.420, eligibility criteria for participation.
D Applying for the CCC Facility Guarantee Program (FGP) in accordance with 7 C.F.R. Section 1493.220, eligibility criteria for participation.
Name and Address of Applicant's U.S. Office
• Company Name:
• Street Address:

P.O. Box:
..__________, • State: .._____ _v_,

• City:
• Zip (Postal) Code:

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• Telephone:

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Fax:

• E-Mail:
• Contact Name:
1.

• Select One:

OBusiness

0 Private Residence

�================================-,-----;:��:::::::_

Name and Address of Applicant's Headquarters Office (to be completed only if different from above)
Company Name:
Street Address:

P.O. Box: �I ___

City:

State: LI _____v-'I

Zip Code:
(Postal Code):
Country Name:
Telephone:

V

###-###-##11# (if United States)

Fax:

###-###-#### (if United States)

2
Name and Address of U.S. Agent for the Service of Process (to be completed only if Expor ter has no U.S. office)
Name:
P.O . Bo x:'�-- Street Address:'------------- - - - - - - - - � - _ _ _ _ _ _ _ _-:::::
"'
.__________, State: '-------'
City:
Zip Code:
(Postal Code)

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Fax:

Telephone:
E-Mail:
Contact Name:

###-###-##11#

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c__
________ _____

3.

https://apps.fas.usda.gov/cccapp/

USDA - Foreign Agricultural Service - XXXX Office

3.

Select One:

OBusiness

Page 2 of 3

0 Private Residence

Applicant's Legal Form of Doing Business
• Type of Business:
4.

V

lf "0ther", please specify:.___ __ ____,
Country of Incorporation Where Legally Registered (please select a U.S. State if country is the United States)

5.

• Country Name: ._____________v
.:.J U.S. State: L! ______v_,!
Required Exporter Information
Business Web Site:
• Dun & Bradstreet (DUNS)
Number (Site specific):
• Tax ID Number:

##-###-#11##

##-#11##11##

Is the applicant a "small or medium
enterprise" (SME)? An SME is an
enterprise, as described by the
U.S. Census Bureau, with 500
@No OYes
or fewer employees . For the U.S.
Census Bureau's definition of an
enterprise, visit their web s,te:
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.):

l-

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:

6.

V

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:

.,.,

Certification Statements
• Please make one of the following certifications:
O "I certify that the above named applicant� participated in any U.S. Government programs, contracts or agreements during the past three y,
O "I certify that the above named applicant QM participated in U.S. Government programs, contracts or agreements during the past three years."
• Please describe rior partici ation:

---------• Applicant must

□
□

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certify to the following statement(s) by selecting the block(s) below:

All S ection 1493 2sora) certifications are being made in this document. (GSM-FGP)
All Section 1493.60/al certifications are being made in this document. (GSM-102)

7. • Name and Position of Individual Submitting Form:

https://apps.fas.usda.gov/cccapp/