Company Name*

Contact Name*

Contact Title*

Street Address*

No P.O. Box

State*

Zip Code*

Phone Number*

Fax Number*

Email*

Web Page 

Company Activity*

(Select all that apply)

Manufacturer Exclusive Distributor Export Management Company Service Company Exporter Franchisor Sales Representative Wholesaler Retailer Other (Explain)

Products / Services your company wants to export*

Targeted Regions / Sectors*

Does Your Product contain at least 51% U.S. content?* Yes No

Do you have a Representative in Venezuela?* Yes No

Service(s) you would like to purchase*

(Select all that apply)

Customized Market Research Business Facilitation Service International Partner Search Gold Key Service International Partner Search & Gold Key International Company Profile Catalog Show / Trade Event Video Gold Key Service Platinum Key Service Other (Explain)

Comments