Company name 

First name 

Last name 

Salutation  Mr. Ms. Mrs. Miss. Dr.

Title/responsibility 

Company address 

City 

State  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code 

Phone 

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 applicable

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  1-4 5-9 10-19 20-49 50-99 100-499 500-999 1000 or more

Sales method  Direct Agents Distributors Joint Venture Other

Do you have an export promotional budget?  Yes No

Company background 

Product/service name 

Industry 

Please describe the industry your product/service is used in.

Description 

Please describe your product/service.

Users 

Please describe the primary users of your product/service.

Your immediate international objectives 

Countries you are currently exporting to 

Countries you would like to target 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

Trade specialist or office 

If yes, please enter the International Trade Specialist with whom you are now working.

Mark Peters I am not currently working with an Int'l Trade Specialist Other

Other trade specialist or office 

If known, feel free to add the name of your trade specialist if not listed above.

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 U.S. 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 time allows, could you explain your export successes as a result of assistance provided by the U.S. Export Assistance Center 

How were you introduced to our services?  Trade seminar/conference/event Federal government agency Local government agency Local school/university presentation Non-profit trade organization Internet research Referred Other

Which specific event or organization?