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# 									Direct Line Contact Us Form							

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### Direct Line: Contact Us

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              - Name* FirstLast
              - Email* 
              - Business Name* 
              - Address  Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry
              - I represent* -    a U.S. Company 
-    an international company with a U.S. presence 
-    an international company with no U.S. presence 
-    an academic institution 
-    a non-profit 
-    a U.S. government agency 
-    none of the above 

              - Comment 
              -       **U.S. Department of State Direct Line Privacy Act Statement**  **Authorities**:  The collection of your personal information is authorized under 15 U.S.C. Sec. 1512; 22 U.S.C. 2651a; and 22 U.S.C. 2656.  **Purpose**:  The information solicited on this web form will be used to facilitate your registration for Direct Line sessions.  The collected information may be used to track client participation in events and services offered by the Office of Commercial and Business Affairs.  **Routine Uses**:  The information on this form may be shared with the Department of Commerce for offering products and services of the International Trade Administration.  More information on the Routine Uses for the system can be found in the System of Records Notice State-03, Bureau of Economic and Business Affairs Contact List.  **Disclosure**:  Providing this information is voluntary.  Failure to provide this information may result in the Department’s inability to register you for the Direct Line Session.  **Direct Line Terms of Participation**  In order to make the most of your experience and ensure that the Department of State meets your expectations, please accept the following terms of participation.  We will protect business confidential information to the extent provided under Federal law.  *Information Collection*  This information collection is authorized by law (15 U.S.C. 1501 et seq., 15 U.S.C. 171 et seq., 22 U.S.C. 2651a, 22 U.S.C. 2656).  Notwithstanding any other provision of law, no person is required to respond, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number.  Although you are not required to respond, your participation in a U.S. Department of State sponsored Direct Line is contingent on a completed Participation Agreement form.  *Submission of Form*  Submission of this form constitutes your company's consent to participate in the Direct Line program and for the U.S. Department of State to share your company's name and contact information with the U.S. Department of Commerce.  Submission of this form additionally constitutes your company's agreement to be solicited to complete a short follow-on survey from the U.S. Department of State regarding the efficacy of the Direct Line and suggestions for its improvement.  This webinar may be recorded, which recording may include your company's name or the name/likeness of individuals participating on your company's behalf.  Any such recording may be published on Department of State public websites and may be used in future Direct Line marketing materials.  Submission of this form constitutes your company's consent and the consent of any company representative to such recording.  It is your company's responsibility to ensure any representative consent. Participating companies may withdraw their participation at any time by contacting the U.S. Department of State at DirectLineNotification@state.gov.  *Legal Disclaimer*  The Department of State makes every effort to ensure the accuracy and completeness of the information provided to the Company/Participant.  The information is not legal advice but provides insight into the market from which the Company/Participant utilizes its own business judgment in conducting such relations or transactions.  In utilizing the provided information, the Company/Participant is responsible for complying with all applicable laws and regulations of the United States and foreign countries and does not hold the U.S. Department of State liable for any business decisions made.  The U.S. Department of State assumes no responsibility or liability for the actions the Company/Participant may take based on the information provided during the Direct Line.
              - Consent* I agree to the privacy policy outlined above.
              - CAPTCHA 

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Bureau of Economic and Business AffairsDirect LineOffice of Commercial and Business Affairs

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