1.Company Name:

2.Address:

3.Contact name & title:

4. Phone: fax: email:

Telex:

5a. Products and Services you are interested in importing from the U.S. (please be very specific):

5b. Technical specifications/product specification:
5c. Quantity (approx):
5d. US dollar value (approx):
5e. Purchase needed by what date?:
5f. Best way for potential U.S. partners to respond:
mail email fax phone telex

5g. What factors will most influence your purchase or proposal (price, delivery, credit, etc.)?:

5h. What specific information do you require from U.S. suppliers?:

5i. Other information:
a. payment terms
b. shipping terms
c. is a service contract needed?
d. who is the end user?
e. what is the end use?

6a. Are you interested in (please click on one option):
Resale Agent Own use Direct purchase Joint Venture Distributor Foreign Government tender License Investment
Other (please specify):

6b. How would you describe your intentions?(Please click on one option):
immediate purchase, delivery or investment (1-2 months) will purchase in short term ( 2-6 months) will purchase in future ( 6 months or more)
Other (please specify):

6c. What type of buying, investment or licensing relationship are you seeking?
a regular/long term supplier; continual sales small or moderate quantities now, but plan on growing irregular purchase based on best price and terms available as items needed one-time buy only
Other:

7. Business activities your company is involved in (check a maximum of three):
Importer Agent Distributor Retailer Manufacturer
Other:

8. Your bank(s) name and address:
9a. Year your company was established: 9b. No. of Employees: 9c. No. of salespeople:
9d. Annual Sales (please click on one):
less than $500 $500-5,000 $50,000 - 250,000 $250,000 - 500,000 $500,000 $1 million $over $1 million
Other:

9e. Type of company (please click on one):
Private Family Public
10. U.S. firms with which you do business:

I agree to reply as promptly as possible to inquiries from U.S. companies.

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