ITEM 1: Applicant/Organizer Information
Name of Applicant:
Principal Address:
Street
Room or Suite
City
State
Zip
Email:
Name of Applicant’s Controlling Entity, if any (if none enter “none”):
Principal Address:
Street
Room or Suite
City
State
Zip
Individual(s) authorized by the applicant to submit application and to whom all correspondence should be addressed:
Name:
Title:
Address:
Street
Room or Suite
City
State
Zip
Telephone:
Email:
Relationship to Applicant:
ITEM 2: Name and principal address of each member, and of each member’s controlling entity, if any.
(Attach your response to this application, clearly identifying the attachment as response to ITEM 2.)
Note - the members of a Certificate are all firms or entities that are covered by and receive the protection of the Certificate other than
the applicant itself.
ITEM 3: A copy of any legal instrument under which the applicant is organized or will operate. Include copies, as appropriate, of its
corporate charter, bylaws, partnership, joint venture, membership, or other agreements or contracts under which the
applicant is organized.
(Attach your response to this application, clearly identifying the attachment as response to ITEM 3.)
ITEM 4: A copy of the applicant’s most recent annual report, if any, and that of its controlling entity, if any.
To the extent the information is not included in the annual report, or in other documents submitted in connection with this application,
attach a brief description of the applicant’s domestic, import and export operations, including:
(i) The nature of its business; (Export facilitators or intermediaries who are available to export any type of product or service but
who do not manufacture, produce, or directly provide any products or services may respond “all products and services.” To the extent
that a facilitator or intermediary specializes, please describe such products and/or services.)
(ii) The role of the applicant with respect to the proposed Certificate and the Certificate’s members and methods of
operations.
(iii) The location(s) of its operations.
(iv) The geographic location of its customers (foreign and domestic).
This description may be supplemented by a chart or table.
(Attach your response to this application, clearly identifying the attachment as response to ITEM 4.)
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