Application for CCC Export Guarantee and Subsidy Programs



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OMB Number 0551-0037

Qualification Application for CCC Export Guarantee
and Subsidy Programs

Program Applying For:

Please check all that apply:

Applying for the Dairy Export Incentive Program (DEIP) and Export Enhancement Program (EEP) in accordance with 7 C.F.R. Section 1494.301 eligibility criteria for participation.

Applying for the CCC Export Credit Guarantee Programs in accordance with 7 C.F.R. Section 1493.30 and 1493.420, eligibility criteria for participation under the CCC Export Credit Guarantee Program (GSM 102),CCC Intermediate Export Guarantee Program (GSM-103), and Supplier Credit Guarantee Program (SCGP).

Please check all that apply:
	Applying for the Dairy Export Incentive Program (DEIP) and Export Enhancement Program (EEP) in accordance with 7 C.F.R. Section 1494.301 eligibility criteria for participation.
	Applying for the CCC Export Credit Guarantee Programs in accordance with 7 C.F.R. Section 1493.30 and 1493.420, eligibility criteria for participation under the CCC Export Credit Guarantee Program (GSM 102),CCC Intermediate Export Guarantee Program (GSM-103), and Supplier Credit Guarantee Program (SCGP).

Name and Address of Applicant's Headquarters Office:

Name:
Street Address:				P.O. Box:
City:		State:		Zip (Postal Code):
Country:
Telephone:	###-###-#### (if United States)	Fax:	###-###-#### (if United States)

Name and Address of an U.S. Agent for the Service of Process:

Name:
Street Address:				P.O. Box:
City:		State:		Zip:
Telephone:	###-###-####	Fax:	###-###-####
E-Mail:
Contact Name:
Select One:	Business Private Residence

Applicant's Legal Form of Doing Business:

Applicant's legal form of doing business:
If "Other", please specify:

Place of Incorporation or State Where Legally Registered:

Name and Address of the Applicant's U.S. Office:

Please check that which applies:
Company Name:
Street Address:				P.O. Box:
City:		State:		Zip:
Telephone:	###-###-####	Fax:	###-###-####
E-Mail:
Contact Name:
Select One:	Business Private Residence
U.S. Domestic Corporation Foreign Corporation Other Foreign Entity

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 by selecting the block:
	"I certify to the best of my knowledge and belief, that neither the above named applicant nor any of its principals has been debarred, suspended, or proposed for debarment from contracting with or participating in any programs administered by a U.S. Government agency. ("Principals," for the purpose of this certification, means officers; directors; owners of five percent of stock or more; partners; and persons having primary management or supervisory responsibility within a business entity (e.g., General manager, plant manager, head of a subsidiary, division, or business segment, and similar positions).) I further certify that should such debarment, suspension, or notice of proposed debarment occur in the future, the above named applicant will immediately notify CCC."

Name and Position of Individual Submitting Form:
This form must be submitted by an officer of the Company making application.

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 0551-0037. The time required to complete this information collection is estimated to average 36 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.

Last modified: Monday, April 14, 2008 06:13:23 PM