Section A – Contact Details

Company Name

Country of incorporation

TIN/EIN Number

Date of incorporation

Shareholder(s) (please include % of shareholdings)

Director(s)

Telephone(s)

Fax

Web page

Contact person(s) - position

Email Address

PACA License Number

Produce Blue Book Number

Liability Insurance Certificate

Payment terms

Willing to work with third party financing providers (i.e. factors)

Can buy FOB at shipping point?

Authorized Signature