Scribd
Upload
52 views2 pages

Route 37N, Marion, Illinois 62959 Phone: 618-997-9015/ Fax: 618-997-9074/ Email

This document is an export questionnaire required for orders shipping outside the US. It collects information about AR VENZ COMPONENTES INDUSTRIALES LTD, including the company name and address, owners' names and phone numbers, references from three US companies they have done business with, their bank details, and confirmation that they are the end user or will pass the goods to Parmalat Dairy. The authorized representative, Armando Alvarado, signs that the information is accurate and that the company and goods will not be involved in proliferation activities against the US.

Uploaded by

macaco logo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
52 views2 pages

Route 37N, Marion, Illinois 62959 Phone: 618-997-9015/ Fax: 618-997-9074/ Email

This document is an export questionnaire required for orders shipping outside the US. It collects information about AR VENZ COMPONENTES INDUSTRIALES LTD, including the company name and address, owners' names and phone numbers, references from three US companies they have done business with, their bank details, and confirmation that they are the end user or will pass the goods to Parmalat Dairy. The authorized representative, Armando Alvarado, signs that the information is accurate and that the company and goods will not be involved in proliferation activities against the US.

Uploaded by

macaco logo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

11402 Route 37N, Marion, Illinois 62959

Phone: 618-997-9015/ Fax: 618-997-9074/ Email: [email protected]

To Whom It May Concern,

This form is required for all orders shipping outside the U.S. to be�er assist us with clearing you via the U.S. Watch lists
and several other security measures, please provide the following questions:

Pleaselist Your Company’sfull legal name and any DBAnameswhich the Companyoperates under, phone numbers and
addresses(No P.O. Box Addresseswill be accepted).

Company Name: ___AR VENZ COMPONENTES INDUSTRIALES LTD


_______________________________________________________________________

Doing Business As: _____ARVENCIUK_____________________________________________________________________

Mailing Address: ___267 ST LEONARD ROAD SL4 3DR 3DR BERKSHIRE


UK________________________________________________________________________

Physical Address (if different from above): _______________________________________________________

Company Phone Numbers:


_______+447923235682_____________________________________________________________

Pleaseprovide the Company’sOwner’s full legal name and contact phone numbers. If more than two owners, pleaselist
their namesand phone numberson a separate page.

Owner’s Name: _ARMANDO ALVARADO_Owner’s Phone Number: _+447923235682_______

Owner’s Name: _NIKI ALVARADO______ Owner’s Phone Number: __+441344222435_________________________

Pleaseprovide (3) U.S.Companiesthat your Companyhas done businesswith within the past (6) months, if applicable..

Company Name: ________________N/A________________ Contact Name: _____N/A__________________________

Address: ______N/A_____________________City/State/Zip: ____________________Phone: _________________

Company Name: ______N/A__________________________ Contact Name: _______N/A________________________

Address: ___________________________City/State/Zip: ____________________Phone: _________________

Company Name: ________________________________ Contact Name: _______________________________

Address: ___________________________City/State/Zip: ____________________Phone: _________________


Initials: _______________Date: ____________________

Colburn Export Questionnaire Page1 of 2


Pleaseprovide the name, addressand contact phone numbersfor the bank which your company dealswith on a daily
basis.

Bank Name: ___TRANSFERWISE__________________________________ Contact Name: _____________

Bank Address: __LONDON __________________________City/State/Zip: _______LONDON EJ11JJ Phone: 020 3695 0999

Please state the reason for your purchase: _____CUSTOMER SERVICE


___________________________________________________________

Is your company the end user of this purchase (please circle one)? YES OR NO

If you are not the end user, is the end user an individual or business? ________PARMALAT DAIRY_______________

What is the name of the individual or company that is the end user? ___________PARMALAT

___________________________ ________________________________________________________________________

Pleasenote we will also needan individual or businessexport form on file for the end userin order to processall orders.

I hereby declare andcertify that I am an authorized representative of the companylisted on thisexport questionnaire
and that all the information providedherein isto the best of my knowledgetrue, accurateand complete. I verify that
my companyis the end userof the item/s purchased,unlessstated on page two of this export questionnaire. Neither
the companylisted, nor myselfare listed on any U.S.watch lists, nor sanctionedor debarred from trade with within the
United States of America, nor will the item/s purchasedbeusedin any proliferation activities against the United States
of America. I hereby authorize the above referencesto supplyColburnPower & Recreationwith relevant information
concerningthis company’sbusinesswith them.

Authorized Signature: _____ARMANDO ALVARADO______ Date: _08/10/2020____________________

Printed Name: _____ARMANDO _____ALVARADO Title:________ENGINEER ______________________

Note: All information collected with not be made public and will be kept on file with your company information. The above information
is being requested in order to satisfy the United States Government requirements for selling / exporting goods and or services to
locations outside of the United States of America. All information provided will be checked and verified prior to any orders being
processed or ship. The questioner is valid for the period of one year unless any change occurs in the information listed.

Colburn Export Questionnaire Page2 of 2

You might also like