Distributor/ Reseller Profile

Transcription

1 Distributor/ Reseller Profile Galls Order Number: Customer Reference Number: Please complete this form with the requested information as it applies to the transaction referenced above. This information will be used to screen all known parties involved in the transaction as well as obtain any required documentation/ authorization prior to shipping the transaction. Is this order for Stock/ Inventory Replenishment? YES (Complete Section 1) NO (Complete Section 1-3) Section 1: For Stock/ Inventory Replenishment orders the distributor accepts responsibility for meeting the following conditions: The Export Control Classification Number (ECCN) will be assigned and controls adhered to as required by US Export Regulations. Galls/Quartermaster may provide the ECCN upon request. Product will not be sold to any unauthorized parties as per the published denied parties lists provided by the US Government online at Product will not be exported or re-exported to any embargoed destinations or for any prohibited end use. By signing below you acknowledge and accept the above conditions of distribution and sale of Galls/Quartermaster products. The information provided on this documentation has been completed to the best of my knowledge to ensure compliance with all US Trade Regulations. Name of Official: Title: Signature: Date:

2 Section 2: Purchaser (Bill To) Intermediate Consignee Ultimate Consignee / End User Contact Name: City: Telephone (Country Code) Fax #: Are any other parties involved in coordinating this transaction that may or may not be in physical possession of the commodities? (If YES, please complete the following information): Business Name: Contact: Phone: Describe Involvement in transaction:

3 If you have more than one end user for the referenced order, please use the Addendum to provide additional information. Section 3: Agency / Department/ Organization Inquiry The information below is asked to obtain specific details on the Ultimate Consignee (final end user/destination) of the items involved in the transaction. Ultimate Consignee Customer Type: Law Enforcement Fire Department Emergency Service Federal Govt. Agency Private Industry Security Company NAPED Military Federal Law Enforcement Embassies & Consulates Railroads Schools Airports City Purchasing Agent/Agency County Purchasing Hospitals Film & Production Co Hazmat Department Civil Defense Agency Agriculture OTHER: Auto & Repair Svcs Business Service Construction Manufacturing Public Administration Restaurants Retail trades Transportation Utilities Correctional Agency How long has the agency/ department/ organization been established? Please provide a website if available Please describe the business of the agency/department/ organization and how these commodities will be utilized. When not in use, how will these commodities be secured/stored? Please provide the number of employees/personnel in this agency/ department/ organization. Please provide the number of locations for this agency/department/ organization. Have you placed orders with Galls before? Please specify other location/country that you may take the items. Other information The information provided on this documentation has been completed to the best of my knowledge to ensure compliance with all US Trade Regulations. (Name) (Date) (Title) (Company Name) If you have more than one end user for the referenced order, please use the Addendum to provide additional information.

4 Section 2: Section 2: Addendum for Additional End User Information Purchaser (Bill To) Intermediate Consignee Ultimate Consignee / End User Contact Name: City: Telephone (Country Code) Fax #: Are any other parties involved in coordinating this transaction that may or may not be in physical possession of the commodities? (If YES, please complete the following information): Business Name: Contact: Phone: Describe Involvement in transaction:

5 Section 3: Addendum for Additional End User Information Agency / Department/ Organization Inquiry The information below is asked to obtain specific details on the Ultimate Consignee (final end user/destination) of the items involved in the transaction. Ultimate Consignee Customer Type: Law Enforcement Fire Department Emergency Service Federal Govt. Agency Private Industry Security Company NAPED Military Federal Law Enforcement Embassies & Consulates Railroads Schools Airports City Purchasing Agent/Agency County Purchasing Hospitals Film & Production Co Hazmat Department Civil Defense Agency Agriculture OTHER: Auto & Repair Svcs Business Service Construction Manufacturing Public Administration Restaurants Retail trades Transportation Utilities Correctional Agency How long has the agency/ department/ organization been established? Please provide a website if available Please describe the business of the agency/department/ organization and how these commodities will be utilized. When not in use, how will these commodities be secured/stored? Please provide the number of employees/personnel in this agency/ department/ organization. Please provide the number of locations for this agency/department/ organization. Have you placed orders with Galls before? Please specify other location/country that you may take the items. Other information The information provided on this documentation has been completed to the best of my knowledge to ensure compliance with all US Trade Regulations. (Name) (Date) (Title) (Company Name)