Salutation* Mrs Miss Ms Mr

First Name*

Last Name*

Title*

Company Name*

Company Address*

City*

State*

Zip Code*

Telephone*

Fax*

E-mail*

Web Site*

http://

Type of Company* Manufacturer Distributor Export Trading Company Service Other

Year the company was established*

Are the products or services of your company at least 51% U.S. content?* Yes No

Total Annual Sales* Under $1 Million $1-$5 Million $5-$10 Million $10-$25 Million Over $25 Million

Sales Method* Direct Agents Distributors Joint Venture Other

Immediate International Objective*

Have you worked with CS before?*

In the past have you worked with any of the U.S. Department of Commerce offices in the U.S. or abroad or exhibited or participated in a trade event? (trade shows/Trade missions/ Matchmakers)

Yes No

Product/Service Name*

Industry*

What is the industry(s) your product/service is used?

Product/Service Description*

Contact*

Are you currently working with one of our U.S. Department of Commerce offices/U.S. Export Assistance Centers here in the U.S.?

Yes No

If yes, please enter the International Trade Specialist or nearest U.S. Department of Commerce, Export Assistance Center Office with whom you are now working.*

Other Trade Specialist or Office 

In the past 24 months,*

have you or has your company utilized any market research reports or trade promotion programs, or received trade counseling from the USDOC Commercial Service or one of its Export Assistance Centers?

Yes No

If so, have these programs or information assisted you in completing any export sales?* Yes No

If the answer is yes and time allows, could you please explain?*