Company Background
		First Name:
		Last Name:
		Company Name:
		Primary Contact:
		Title:
		Street Address:
		City:
		State:
		Country:
		Phone:
		Mobile:
		Fax:
		Email:
		Website:
		Passport #:
		Dual Citizenship:		Yes     No
				Business Activity (please check all that apply)
		E-Government		Wholesaler
		Sales Agent		Distributor
		Import Trading Co.		Commissioned Sales Representative
		Retailer		Export Management Company
		Management		Funding/Finance
		Explain if Other:
				Corporate Structure
				How many years have you been in business?
				What countries do you service?
				Annual sales in U.S. dollars.
				Principal Markets Served (please check all that apply)
		Government		Brokers
		States		Investors
		Municipalities		Stores
		Dealerships		Industrial
		Institutions		Financial
		Entrepreneurs		Other
		Account Age:		(In Years)
				Customer Profile
				Please list your company's main customer accounts for the products and territories cited above.
		Customer:		Products:
		Customer:		Products:
		Customer:		Products:
				Additional Information
		Please fax, mail, or email any other information highlighting your qualifications to be an international sales representative.  Please note that the contents of this questionnaire and any additional information provided by you will be used for the sole purpose of evaluating your qualifications as a representative of our technology transfer, products, services, licenses and franchises.  All information is strictly confidential.  Our fax number is 805.643.4386.  Our mailing address is FranTech International Licensing Inc. 2299 Main St. Suite #11, Ventura, California  93001  U.S.A.  Our email address is Director@InternationlLicensing.com .
				Questionnaire Completed By
		Name:
		Title:
		Date:
		Primary Contact:
		Primary Contact Title: