Company Name*

First Name*

Last Name*

Salutation  Mr. Ms. Mrs. Miss. Dr.

Title 

Company Address*

City*

State*

Zip Code*

Telephone*

Fax 

Email*

Web Site 

Type of Company* Manufacturer Distributor Export Trading Company Service Other

Year firm was established*

If you are not a Manufacturer, do you or your firm have documented right to export the product or service?* Yes No Not Applicaple

Is your product/service 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

Percentage export 

Number of employees in the company.  1-4 5-9 10-19 20-49 50-99 100-499 500-999 1000 and over

Sales Method* Direct Agents Distributors Joint Venture Other

Do you have an export promotional budget?* Yes No

Company Background*

Product/service name 

Product/service is used in the following industry. 

Product/Service Description 

Primary product/service users 

Your immediate international objectives 

Countries you are currently exporting to. 

Countries you would like to target for export in the next 12/18 months. 

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. 

(Names listed are members of our Silicon Valley staff, not a complete list of all Commercial Service staff.) If known, feel free to add the name of your Trade Specialist or closest office if not listed:

Silicon Valley Office - Joanne Vliet - Keith Hwang - Mari Felton Other

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 yes and time allows, could you please explain?