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This application is to be completed by an exporter (or a broker acting
on its behalf) in order to obtain a short-term insurance policy covering
sales to a single foreign buyer. Repayment terms can be up to 360 days.

An online version of this application is available on Ex-Im Bank's web
site. Ex-Im Bank encourages customers to apply on line, as it will
facilitate our review and allow customers a faster response time.
Additional information on how to apply for Ex-Im Bank insurance can be
found on Ex-Im's web site [http://www.exim.gov](http://www.exim.gov/).

Send this completed application to Ex-Im Bank, 811 Vermont Ave., NW,
Washington, D.C. 20571. Ex-Im Bank will also accept e-mailed pdf and
faxed applications. Ex-Im Bank will not require the originals of these
applications to be mailed. The application must be PDF scans of original
applications and all required attachments. (Fax number 202.565.3380,
e-mail <exim.applications@exim.gov>)

# APPLICATION FORM

**Applicant/Exporter**

The applicant/exporter is the U.S. entity that contracts with the buyer
for the sale of the U.S. goods and services.

Applicant legal name: State:

Contact person: Country:

Position title: E-mail:

Street Address: Phone:

City: Zip Code: Fax:

**Broker (if applicable):**

Name of Broker:

Ex-Im Bank Broker#:

Contact Person:

Fax:

E-mail:

**1. GENERAL QUESTIONS**

**A. Type of Coverage Requested**

Comprehensive risk

Political risk

**B. Qualification for Coverage**

Will the applicant have title to the products at the time they are
shipped?

> Yes No

Will the applicant directly invoice the buyer?

> Yes No
>
> If you answered no to either, you may not be eligible for coverage.
> Call Ex-Im Bank or your broker for assistance.

### C. Primary Reason for applying for this policy

Risk mitigation

Financing

To offer more competitive terms

**D. Is this a resubmission of a previously withdrawn, returned or
denied application, or a follow-on policy for the same buyer?**

Yes

No

If yes, indicate previous transaction number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**E. Primary point of contact for this application**

Exporter

Broker

**2. SPECIAL COVERAGES**

Check the boxes for the special coverage that apply to this transaction.
Complete and attach the requested forms, where applicable.

+-----------------------+-----------------------+-----------------------+
| Pre-shipment Cover    | Shipment to address   | Additional Named      |
|                       | in US                 | Insured Attachment    |
| Attachment II --      |                       | IV - ANI required     |
| Pre-shipment          |                       |                       |
| questionnaire         |                       |                       |
| required              |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Bulk agriculture      | Enhanced assignment   | Services              |
|                       |                       |                       |
|                       | Attachment III - EA   |                       |
|                       | questionnaire         |                       |
|                       | required              |                       |
+-----------------------+-----------------------+-----------------------+
| Warehouse             | Foreign currency      | Other                 |
|                       | coverage              |                       |
| Attachment V --       |                       |                       |
| Warehouse information | indicate              |                       |
| required              | currency:\_\_\_\_     |                       |
|                       |                       |                       |
|                       | \- currency of supply |                       |
|                       | contract              |                       |
|                       |                       |                       |
|                       | US dollar             |                       |
|                       |                       |                       |
|                       | foreign currency      |                       |
+-----------------------+-----------------------+-----------------------+

**3. PARTICIPANTS**

Provide information on the additional participants to the transaction.

**Supplier**

The supplier is the U.S. entity that manufactures the goods and/or
performs the services to be exported. Check if the exporter is the
supplier and there are no additional suppliers. Enter any additional
suppliers, or check various:

Supplier legal name: State:

Contact person: Country:

Position title: E-mail:

Street Address: Phone:

City: Postal Code: Fax:

OMB #3048-0018

Expire 7/31/09

**Buyer**

The buyer is the entity that contracts with the exporter for the
purchase of U.S. goods and services.

Buyer legal name: State:

Contact person: Country:

Position title: E-mail:

Street Address: Phone:

City: Postal Code: Fax:

### Guarantor

The guarantor is the person or entity that agrees to repay the credit if
the buyer does not. Refer to the Short-Term Credit Standards to
determine in what circumstances personal or corporate guarantors are
required.

Is a guarantor involved in this transaction? Yes No

If yes, is the guarantor an individual or a company?

Guarantor legal name: State:

Contact person: Country:

Position title: E-mail:

Street Address: Phone:

City: Postal Code: Fax:

**End-user**

The end-user is the foreign entity that uses the U.S. goods and
services:

Check if the end-user is also the buyer.

End-user legal name: State:

Contact person: Country:

Position title: E-mail:

Street Address: Phone:

City: Postal Code: Fax:

**Agent**

An agent is a business entity or individual located in the country of
the borrower or buyer who has assisted in the sourcing, packaging,
and/or preparation of a request for support from Ex-Im Bank, and which
will receive compensation in some form for their services.

Is an agent involved in this transaction? Yes No

If yes, add the agent information below:

Agent legal name: State:

Contact person: Country:

Position title: E-mail:

Street Address: Phone:

City: Postal Code: Fax

**Related Parties**

Describe any direct or indirect ownership or family relationship that
exists between any of the participants. If none, so indicate: None.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Primary Source of Repayment**

The PSOR is the entity whose financial statements or credit information
form the basis of Ex-Im Bank's evaluation of reasonable assurance of
repayment, i.e. the entity whose financial statements Ex-Im Bank uses to
supply calculate the ratios for Short-Term Credit Standards compliance.
For this transaction, indicate whether the PSOR is:

the buyer,

the corporate guarantor, or

business combination, (e.g. the consolidated or combined financial
statements of the buyer and one or more corporate guarantors.). Indicate
which entities comprise the
combination\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is the PSOR a financial institution? Yes No

Select the risk category of the PSOR: Private sector Public sector

Does the PSOR have a bond rating? Yes No

If yes, indicate the name of the rating agency, rating, and the date of
the rating.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**4. TRANSACTION DESCRIPTION AND ELIGIBILITY**

Indicate whether the sale represents a:

Firm order

sale in negotiations

response to an invitation to bid

Provide a description of the products or service, including their NAICs
code, if known:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Regarding the above products or services...

Is each product produced or manufactured in the United States? Yes No

Has at least one-half of the value, exclusive of mark-up, been added by
labor or material exclusively of United States origin? Yes No

Are these products on the munitions control list? Yes No

Are the products new or used? New Used

Are the products capital goods that will be used to produce exportable
products? Yes No

Will any value be added to the product after export from the U.S.? Yes
No

If yes, provide an explanation:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Has this transaction been considered by any other export credit insurer?
Yes No

If yes, provide details:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**5. FINANCED AMOUNTS AND STRUCTURE**

Enter the %s for each payment term the exporter will extend to the buyer

Number of shipments: single multiple under one sales contract

Expected date(s) of shipment:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Estimated shipment volume to be insured:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If multiple shipments, the expected highest amount outstanding during
the shipment period: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Other security available:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**6. CREDIT INFORMATION ON THE PSOR**

The information requested in Attachment I: Credit Information is
attached.

**7. NOTICES AND CERTIFICATIONS**

**Certifications**

The applicant certifies that neither it, nor its Principals, have within
the past 3 years been a) debarred, suspended, declared ineligible from
participating in, or voluntarily excluded from participation in, a
Covered Transaction, b) formally proposed for debarment, with a final
determination still pending, c) indicted, convicted or had a civil
judgment rendered against it for any of the offenses listed in the
Regulations, d) delinquent on any substantial debts owed to the U.S.
Government or its agencies or instrumentalities as of the date of
execution of this application; or e) the undersigned has received a
written statement of exception from Ex-Im Bank attached to this
certification, permitting participation in this Covered Transaction
despite an inability to make certifications a) through d) in this
paragraph.

The applicant further certifies that it has not and will not knowingly
enter into any agreements in connection with the Goods and Services with
any individual or entity that has been debarred, suspended, declared
ineligible from participating in, or voluntarily excluded from
participation in a Covered Transaction. All capitalized terms not
defined herein shall have the meanings set forth in the Ex-Im Bank
Suspension and Debarment Regulations at 12 C.F.R. Part 413
(Regulations).

In addition, the applicant further certifies that it has not, and will
not, engage in any activity in connection with this transaction that is
a violation of a) the Foreign Corrupt Practices Act of 1977, 15 U.S.C.
78dd-1, et seq. (which provides for civil and criminal penalties against
individuals who directly or indirectly make or facilitate corrupt
payments to foreign officials to obtain or keep business), b) the Arms
Export Control Act, 22 U.S.C. 2751 et seq., c) the International
Emergency Economic Powers Act, 50 U.S.C. 1701 et seq., or d) the Export
Administration Act of 1979, 50 U.S.C. 2401 et seq.; nor been found by a
court of the United States to be in violation of any of these statutes
within the preceding 12 months, and to the best of its knowledge, the
performance by the parties to this transaction of their respective
obligations does not violate any other applicable law.

The applicant certifies that the representation made and the facts
stated in this document and any attachments are true, to the best of its
knowledge and belief, and it has not misrepresented or omitted any
material facts, and if any of the certifications made herein become
untrue, Ex-Im Bank will be promptly informed of such changes. The
applicant further understands that these certifications are subject to
the penalties for fraud against the U.S. Government (18 USC 1001, et
seq.).

**Notices**

The applicant is hereby notified that information requested by this
application is done so under authority of the Export-Import Bank Act of
1945, as amended (12 USC 635 et seq.); provision of this information is
mandatory and failure to provide the requested information may result in
Ex-Im Bank being unable to determine eligibility for support. The
information provided will be reviewed to determine the participants'
ability to perform and pay under the transaction referenced in this
application. Ex-Im Bank may not require the information and applicants
are not required to provide information requested in this application
unless a currently valid OMB control number is displayed on this form
(see upper right of each page).

Public Burden Statement: Reporting for this collection of information is
estimated to average 1 hour per response, including reviewing
instructions, searching data sources, gathering information, completing,
and reviewing the application. Send comments regarding the burden
estimate, including suggestions for reducing it, to Office of Management
and Budget, Paperwork Reduction Project OMB# 3048-0009, Washington, D.C.
20503.

Applicant (Exporter) name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name and title of authorized
officer:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of Authorized
officer:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#   {#section .unnumbered}

#  APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE

**Attachment I: Credit Information Requirements**

Directions: The required credit information depends on whether the PSOR
is the buyer or corporate guarantor, or a financial institution
guarantor and on the amount of credit support requested. Check the boxes
that are applicable to your transaction.

**1.** **The PSOR is not a financial institution:**

a\) Provide details of the exporter's experience with the buyer

> Does the exporter have any experience selling to the buyer? Yes No

If yes, provide the following information:

Date of first sale to the buyer: \_\_\_\_\_\_     

Date of first credit sale to the buyer: \_\_\_\_\_\_     

Historic credit experience with the buyer:

  ----------------- ----------------- ----------------- -----------------
  **Yearly Credit   **Current year**  **Prior year 1**  **Prior year 2**
  Experience**                                          

  Total amount sold                                     

  Total amount on                                       
  credit                                                

  Highest amount                                        
  outstanding for                                       
  which exporter                                        
  has been paid                                         

  Payment                                               
  terms/tenor                                           
  ----------------- ----------------- ----------------- -----------------

Amount now owing:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Payment history: prompt 1 -- 30 days slow 31 -- 60 days slow more than
60 days slow

Is there an amount past due? yes no

If yes, enter amount due and due dates.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Provide reasons for past dues:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If past dues were due to foreign exchange problems, does applicant have
evidence of local currency deposits on all payments due? yes no

> b\) Provide the applicable supporting financial information on the
> PSOR. Check the box that applies to your transaction and provide the
> information noted below the box

The transaction is for an amount up to \$50,000:

-   credit agency report *[or]{.underline}* trade reference or
    applicant's ledger experience

The transaction is between \$50, 001 and \$100, 000:

-   credit agency report *[and]{.underline}* trade reference or
    applicant's ledger experience

The transaction is between \$100,001 and \$300, 000:

-   credit agency report,

-   two trade references or one trade reference and applicant's ledger
    experience, or

-   two most recent years signed fiscal year-end statements

The transaction is between \$300, 001 and \$ 1,000,000:

-   credit agency report

-   two trade references

-   audited or signed, unaudited financial statements for the last two
    fiscal years that adequately disclose financial condition and afford
    a reasonable basis for reliance on the information provided.

# APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE

> The transaction is between \$1,000,001 - \$10,000,000

-   credit agency report

-   two trade references

-   bank reference

-   audited or signed unaudited financial statements for the last three
    fiscal years that adequately disclose financial condition and afford
    a reasonable basis for reliance on the information provided.

**2.** **The PSOR is the financial institution guarantor.**

a\. Provide details of the exporter's experience with the financial
institution guarantor. Include dates and amounts of previous
transactions with the PSOR or indicate None
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> b\. Provide supporting financial information.

Check the box that applies to your transaction and provide the
information noted below the box

The transaction is for an amount up to \$1 million:

-   One favorable reference from creditor bank.

```{=html}
<!-- -->
```
-   One short-term debt rating of the PSOR from S & P, Moody's or Fitch
    IBCA. Ratings must be B, P-3 or F3 or better, respectively.

> OR

-   Most recently published fiscal year end or interim statements or
    statement spreads from Fitch IBCA, or Bankscope.

The transaction is for between \$1,000,001 and \$10,000,000

-   One favorable reference from a creditor bank

-   If the PSOR does not have an acceptable current market rating,
    provide most recently published audited financial statements that
    adequately disclose financial condition and were prepared in
    accordance with to accounting principles that afford a reasonable
    basis for reliance on the information provided.

# APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE

## Attachment II

## Pre-shipment Questionnaire

Details of Coverage Requested

a\) Provide the reason pre-shipment coverage is requested
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\) Indicate the date the contract was executed or the anticipated date
of signing

c\) Indicate the estimated period between the contract date and the
final shipment date

d\) Provide a schedule of any progress payments made or to be made by
the buyer or during the pre-shipment period, or indicate none:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE

## Attachment III. Enhanced Assignment Questionnaire

If requesting Enhanced Assignment, attach

-   A bank reference on the exporter/applicant dated within six months
    of the application

-   Two trade references dated within six months of the application

-   Financial statements on the exporter/applicant as follows, for a
    policy limit of liability of:

> \$500,000 or less signed by an authorized officer for the
> applicant/exporter
>
> \$500,001 - \$999,999 reviewed by a CPA with notes attached
>
> \$1,000,000 or more audited by a CPA with opinion and notes attached

# APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE

**Attachment IV Additional Named Insured Questionnaire**

Indicate the name of the additional named insured as follows:

Legal Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

State:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Country:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Zip/ Postal Code:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Relationship to Applicant:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Role in the transaction:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

E-mail:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact person:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# APPLICATION FOR EXPORTER SHORT-TERM, SINGLE-BUYER INSURANCE

**Attachment V -- Warehouse Information**

If you requested the Special Coverage -- Warehouse, answer the following
questions about the warehouse

Warehouse Type: Owned or controlled by exporter

> Bonded warehouse
>
> Neither

Warehouse Location**:** City
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

State/Province
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Country\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_