Advocacy Questionnaire

FORM ITA-4133P
Page 1 of 6

OMB No. 0625-0220
Expires 10/31/2009

ADVOCACY QUESTIONNAIRE
United States Government advocacy decisions are made on the basis of the best information available. To
assist us in responding effectively to your company's request for advocacy, please submit this
Questionnaire (including the information requested on the following pages) and other relevant materials
to your USG contact or to the Advocacy Center (“AC”), U.S. Department of Commerce, Room 3814A,
Washington, D.C. 20230, Phone: (202) 482-3896, Fax: (202) 482-3508. Please also complete the
attached “Agreement Concerning Bribery and Corporate Policy Prohibiting Bribery.”
This Questionnaire should be completed by the bidder for the project, except in special circumstances as
determined by the AC. Subcontractors or suppliers should not complete this form unless requested by the
AC. If you are awarded a project for which USG advocacy has been provided, the Advocacy Center may
follow-up to assess the effectiveness of our assistance and the benefits to the U.S. economy. Companies
are responsible for promptly informing the AC of any material changes in the information provided.
Freedom of Information Act: Information submitted to the government may be subject to disclosure
pursuant to the Freedom of Information Act. However, all confidential commercial information will be
protected from disclosure to the extent permitted by law. You will be notified if any such information
submitted by you is responsive to a Freedom of Information Act request.
Name and Location of the Project:
Name of Company:
Place of Incorporation:
Place of Domicile:
Company Reference Information:
Ownership (identify any parent companies):
Annual Sales ($):
Number of Employees:
Address:
Contact and Title:
Contact Information:

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
EIN:___________________ D&B #:___________________
_________________________________________________
_________________________________________________
U.S.:________________Outside U.S.:__________________
_________________________________________________
_________________________________________________
Phone:___________________Fax:_____________________

Certification
The undersigned, being so authorized, certifies on behalf of the Company that, to the best of his/her
knowledge, the information provided herewith is complete and accurate, and that the Company is in
compliance with applicable U.S. la w including the Foreign Corrupt Practices Act.
___________________________________
Signature of Authorized Company Official

_________________________________
Date

___________________________________
Typed Name of Authorized Company Official

_________________________________
Typed Title of Authorized Company Official

This Questionnaire is also available at our website: http://export.gov/Advocacy/questionnaire.html. If the
Questionnaire is submitted electronically, the signed signature page and Agreement Concerning Bribery and
Corporate Policy Prohibiting Bribery must be scanned and emailed or provided by mail or fax.
Public Reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer, International Trade Administration,, Room 4001, U.S. Department of
Commerce, Washington, D.C. 20230 and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Paperwork Reduction Project (0625-0125),
Washington, D.C. 20503 February 2006

FORM ITA-4133P
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OMB No. 0625-0220
Expires 10/31/2009

Please respond in detail to each question below. Include additional sheets of paper if necessary.
A. PROJECT/TRANSACTION:
1. Description of the foreign project/transaction:

2. Total value of the project/transaction (e.g., the estimated contract value specified in U.S.
dollars). Identify separately value(s) to be provided by domestic and/or foreign partners
in a consortium, if applicable:

3. U.S. export content to be provided by your company.
• U.S. goods being provided:

•
•

Value (in USD) of U.S. goods:
U.S. services being provided:

• Value (in USD) of U.S. services:
4. U.S. export content to be provided by other company(ies).
• U.S. goods being provided:

•
•

Value (in USD) of U.S. goods:
U.S. services being provided:

•

Value (in USD) of U.S. services:

February 2006

FORM ITA-4133P
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OMB No. 0625-0220
Expires 10/31/2009

5. Goods and services provided from abroad.
• Goods being provided from abroad:

•
•

Value (in USD) of non-U.S. goods:
Services being provided from abroad:

• Value (in USD) of non-U.S. services:
6. Status of project/transaction or current stage of bid process, and expected interim and
final decision date(s):

7. Name and title of foreign government decision-maker(s):
a. _________________________________________________________________
b. _________________________________________________________________
c. _________________________________________________________________
d. _________________________________________________________________
8. Are you bidding in a partnership or a consortium with other companies? If yes:
a. Ownership/structure/control of consortium (provide percentages where
applicable):

b. Name, nationality, address, telephone number, contact name and title of the
company’s partners and/or consortium members:

c. Name and nationality of the “Bidder of Record”:
d. Anticipated role of each partner and/or member of the consortium:

February 2006

FORM ITA-4133P
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OMB No. 0625-0220
Expires 10/31/2009

e. Additional information on partners and/or consortium members, or officers or
shareholders of partners and/or consortium members, of which the USG should be
aware:

9. How will this project/transaction affect the environment?

10. Will any items or technology to be exported in connection with this project/transaction
require U.S. Government export licenses (e.g., a Department of State license or a
Department of Commerce license)? If yes, status of application(s)?

B. REQUEST FOR ADVOCACY:
1. Type of assistance requested. Be as specific as possible:

2. Reason for requested assistance:

3. Please highlight the competitiveness of your bid in terms of technology and price:

4. Has your company, partner(s), or any member of your consortium requested or received
advocacy or any other assistance from a foreign government in connection with this
project/transaction? If yes, please explain.

5. How does your company plan to finance this project/transaction?

February 2006

FORM ITA-4133P
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OMB No. 0625-0220
Expires 10/31/2009

6. Has your company – or any member of your consortium – applied for
financing/support from any public export finance institution (e.g. EXIM, OPIC, foreign
export financing agencies)?

a. If yes, provide status of application:

b. If no (as of completion of Questionnaire), indicate whether you plan to seek such
financing/support in future:

C. COMPETITORS:
1. Please identify all known competitors for this project/transaction and their nationalities,
including all U.S. and foreign companies/enterprises.

2. To your knowledge, have any of the competitors listed above sought or received foreign
government advocacy in connection with this project/transaction? If yes, please explain
and identify the source and type of advocacy.

D. EXPECTED EFFECTS ON U.S. ECONOMY:
1. What are the expected direct and indirect effects on U.S. jobs, including effects on small
and medium sized enterprises, which may result if this project/transaction is awarded to
USG advocacy petitioner?

2. From what State(s) will exports be sourced should this project/transaction be awarded to
the USG advocacy petitioner?

3. Please identify any other foreseeable material benefits to the U.S. economy expected to
derive from the USG advocacy petitioner’s bid or from its role in the project/transaction.

February 2006

AGREEMENT CONCERNING BRIBERY AND
CORPORATE POLICY PROHIBITING BRIBERY
Agreement:

__________________________________________________ (“the Company”) has requested
advocacy assistance for the _____________________________________________________
project/transaction in ___________________________________. In connection with this
request the Company agrees that it and its Affiliates:

(1) have not and will not engage in the bribery of foreign public officials in connection with
the above matter; and
(2) maintain and enforce a policy that prohibits the bribery of foreign public officials.
The Company understands that failure to comply with the terms of this Agreement may result
in the denial of advocacy assistance.
Definitions:
For purposes of this Agreement:
The term “Affiliate” means (a) any company that holds, directly or indirectly, a majority of the
voting stock of the Company; and (b) any other company the majority ownership of whose
voting stock is held, directly or indirectly, by the Company or by a company described in (a).
The term “bribery of foreign public officials” has the meaning of the term “bribery of foreign
public officials” in the OECD Convention on Combating Bribery of Foreign Public Officials in
International Business Transactions. In addition, for companies that are subject to the Foreign
Corrupt Practices Act of 1977 (FCPA), the term "bribery of foreign public officials" refers to
practices prohibited by the FCPA (see 15 U.S.C. §§ 78dd1, 78dd2, and 78dd-3).

_________________________________
[Name of the Company]

by: _________________________________
[Signature]
_________________________________
[Type/Print Name]
_________________________________
[Title]
February 2006

Date: ____________________________