Salutation* Mr. Mrs. Ms. Miss Dr.

First Name*

Last Name*

Title 

Company Name*

Company Address*

City*

State*

Zip Code*

Telephone*

Fax*

Email*

Web Site 

Type of Company* Manufacturer Distributor Export Trading Company Service Other

Year the firm was established*

Are the products or services to be sold abroad at least 51% US 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 

Worked with CS 

In the past have you or your firm worked with any of the U.S. Dept. 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 

Select the Industry your product/service is used in.

Accounting Services Advanced Ceramics Advertising Services Agricultural Chemicals Agricultural Machinery and Equipment Agricultural Services Air Conditioning/Refrigeration Equipment Aircraft/Aircraft Parts Airport/Ground Support Equipment Apparel Architectural/Construction/Engineering Services Artwork Audio/Visual Equipment Automobiles/Light Trucks/Vans Automotive Parts/Services/Equipment Aviation Services Biotechnology Books/Periodicals Building Products Business Equipment (Non-Computer) Chemical Production Machinery Coal Commercial Fishing Equipment Commercial Vessels and Equipment (Non-Fisheries) Composite Materials (Plastic/Ceramic/Metallic) Computer Services Computer Software Computer Software and Services Computers/Peripherals Construction Equipment Consumer Electronics Cosmetics /Toiletries Defense Industry Equipment Dental Equipment Drugs/Pharmaceuticals Economy Education/Training Services Electrical Power Systems Electronic Components Electronics Industry Production/Test Equipment Employment Services Films/Videos Financial Services Fishing Equipment Food Processing/Packaging Equipment Foods - Processed Footwear Forestry/Woodworking Machinery Franchising Furniture General Consumer Goods General Industrial Equipment/Supplies General Science and Technology General Services Giftware Health Care Services Hotel/Restaurant Equipment Household Consumer Goods Industrial Chemicals Industry Not Listed Information Services Insurance Services Investment Services Iron/Steel Jewelry Laboratory Scientific Instruments Lawn/Garden Equipment Leasing Services Leather/Fur Products Machine Tools/Metalworking Equipment Management Consulting Services Marine Fisheries Products (Seafood) Materials Handling Machinery Medical Equipment Mining Industry Equipment Musical Instruments Non-Ferrous Metals Oil/Gas Field Machinery Oil/Gas/Mineral Production/Exploration Services Operations/Maintenance Services Packaging Equipment Paper/Paperboard Pet Foods/Supplies Photographic Equipment Plastics Materials/Resins Plastics Production Machinery Pleasure Boats/Accessories Pollution Control Equipment Port/Shipbuilding Equipment Printing/Graphic Arts Equipment Process Controls - Industrial Pulp/Paper Machinery Pumps/Valves/Compressors Railroad Equipment Regulations Renewable Energy Equipment Robotics Security/Safety Equipment Sporting Goods/Recreational Equipment Telecommunications Equipment Telecommunications Services Textile Fabrics Textile Machinery/Equipment Textile Products - Made-Up Tools - Hand/Power Toys/Games Trade Promotion Services Transportation Services (other than Aviation) Travel/Tourism Services Trucks/Trailers/Buses Used/Reconditioned Equipment Veterinary Medicine Equipment/Supplies Water Resources Equipment/Services Yarns Other

Additional industries 

Product/service description 

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 Illinois 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:

Chicago Office Libertyville Office Peoria Office Rockford Office IL, Julie Carducci-Chicago IL, Patrick.Hope-Rockford IL, Robin Mugford-Libertyville IL, Debra Rogers-Chicago IL, Bernadine Smith-Chicago IL, Shari Stout-Peoria IL, Connie Tinner-Chicago IL, Thelma Young-Chicago I am not currently working with an Int'l Trade Specialist 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?