Qualification Application for CCC Export Credit Guarante

OMB Control No. #0551-0004

Expiration Date: 5/31/2024

Qualification Application for CCC Export Credit Guarantee Programs

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Fields marked with an asterisk (*) are required

Program Applying For:

* Please check all that apply:

Applying for the CCC GSM-102 Export Credit Guarantee Program in accordance with 7 C.F.R. Section 1493.30, eligibility criteria for participation.

Applying for the CCC Facility Guarantee Program (FGP) in accordance with 7 C.F.R. Section 1493.220, eligibility criteria for participation.

1. Name and Address of Applicant's U.S. Office

*Company Name:
*Street Address:				P.O. Box:
*City:		State:
*Zip Code: (Postal Code)	-
*Telephone:	###-###-####	Fax:	###-###-####
*E-Mail:
*Contact Name:
Select One:	Business       Private Residence

* Please check that which applies:

            U.S. Domestic Corporation     Foreign Corporation     Other Foreign Entity

2. Name and Address of Applicant's Headquarters Office (to be completed only if different from above)

* Company Name:
* Street Address:					P.O. Box:
* City:			State:
Zip Code:  (Postal Code):		-
* Country Name:
* Telephone:		##########	Fax:	##########

3. Name and Address of U.S. Agent for the Service of Process (only to be completed if Exporter has no U.S. office)

   *Name:
   *Street Address:				P.O. Box:
   *City:		State:
   *Zip Code: (Postal Code)	-
   *Telephone:	###-###-####	Fax:	###-###-####
   *E-Mail:
   *Contact Name:
   Select One:	Business       Private Residence

4. Applicant's Legal Form of Doing Business

Applicant's legal form of doing business:

* Type of Business:

5. Country of Incorporation Where Legally Registered (please select a U.S. State if country is the United States)

*Country Name:

U.S. State:

6. Required Applicant Information

   Business Web Site:
   * Dun & Bradstreet (DUNS) Number (Site specific):	##-###-####
   * Tax ID Number:	##-#######
   Is the applicant a "small or medium enterprise" (SME)? An SME is an enterprise, as described by the U.S. Census Bureau, with 500 or fewer employees. For the U.S. Census Bureau's definition of an enterprise, visit their web site:	No  Yes
   List any related companies (i.e. affiliates, subsidiaries, or companies otherwise related through common ownership) currently qualified to participate in CCC export programs:
   Nature of applicant's business (i.e. agricultural producer, trader, consulting firm, etc.):
   FGP Applicants: Explanation of the applicant's experience/history with agricultural commodities, goods or services for the preceding three years including a description of the commodities or goods or services:
   GSM-102 Applicants: Explanation of the applicant's experience/history with exporting U.S. agricultural commodities, including the number of years involved in exporting, types of products exported and destination of exports for the preceding three years:

7. Certification Statements

* Please make one of the following certifications:
	"I certify that the above named applicant has not participated in any U.S. Government programs, contracts or agreements during the past three years."
	"I certify that the above named applicant has participated in U.S. Government programs, contracts or agreements during the past three years." * Please describe prior participation:
* Applicant must certify to the following statement(s) by selecting the block(s) below:
	All Section 1493.60(a) certifications are being made in this document. (GSM-102)
	All Section 1493.250(a) certifications are being made in this document. (GSM-FGP)

6. 
   * Name and Position of Individual Submitting Form:
     
   (This form must be submitted by an “officer” of the Company making application. Please also fax a copy of your Articles of Incorporation to (202) 720-2949)

     

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