Legal Title *

Business Title **

Address*** 1.Line

Address 2.Line

Address 3.Line

City

State/Province/Region

Zip/Post code

Country

Phone Number

Fax Number

URL

E-mail

Tax Authority

Tax Registry   Number

Number of   Employee
  (Yearly average)

Total Sales in   USD

(last year)

Year of   Establishment

Legal(Corporate)Status

International quality certificates owned and their   registry numbers

Countries products are exported to

Export   country(ies)

Product(s)

I hereby declare that the information   presented above is correct and verifiable.

Name surname and   title in the company

Company stamp and   sign of the authorized person