Export-Import Bank
of the
United States
___________________________________________________________________________
EIB10-01A
OMB 3048-xxxx
Expires:
The Export-Import Bank of the United States (“Ex-Im Bank”) requires your company to complete and return this Questionnaire to Ex-Im Bank within ten days. In addition, Ex-Im Bank reserves the right to ask further questions as necessary.
Part A: General Information
1. Company Information:
Company Name: ____________________
Address: ____________________
____________________
____________________
Contact:
Name and Title: ____________________
Telephone: ____________________
Email: ____________________
2. Does the company produce, refine, or sell petroleum, refined petroleum products, oil, or natural gas?
Yes
No
3. Is the company a direct or indirect subsidiary of another company that produces, refines, or sells petroleum, refined petroleum products, oil or natural gas?
Yes
No
If you answered yes, list each company’s name, together with the address of its main or head office(s) and contact information:
Company: ____________________
Address: ____________________
____________________
____________________
Contact:
Name and Title: ____________________
Telephone: ____________________
Email: ____________________
Part B: Certification
Certification. The submitter of this questionnaire (“Submitter”) certifies that the facts stated and the representations made above and in any attachments to this Questionnaire are true, to the best of the Submitter’s knowledge and belief after due diligence, and that the Submitter has not misrepresented or omitted any material facts. The Submitter further understands that this is an official submission to the United States Government and this Certification is subject to the penalties for fraud against the U.S. Government (18 U.S.C. § 1001, et. seq.). The Submitter further certifies that it will provide additional information with respect to any of the matters covered in this Questionnaire upon Ex-Im Bank’s request. The authorized officer or employee signing below is fully authorized to certify the answers in this Questionnaire on behalf of the Submitter.
Company Name: ___________________________
By: ___________________________
(Authorized Officer or Employee)
Name:
Title:
Date: ___________________________
Public Burden Statement - Reporting for this collection of information is estimated to average xx hours per response, including reviewing instructions, searching data sources, gathering information, and completing and reviewing the application. Send comments regarding the burden estimate, including suggestions for reducing it, to Office of Management and Budget, Paperwork Reduction Project OMB# 3048-XXXX, Washington, D.C. 20503.
811 Vermont Avenue, N.W. Washington, D.C. 20571
File Type | application/msword |
Author | BRAUN |
Last Modified By | siddiqui |
File Modified | 2010-07-21 |
File Created | 2010-07-21 |