Agents Vetting Questionnaire - Global Hub

Company Information

Agents Vetting Questionnaire
Company Name*
Logo

Browse Files

Cancelof
Head Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Country CodeArea CodePhone Number
Email*
example@example.com
Website
www.websitedomain.com
Key Vendor Contact
Full Name*

PrefixFirst NameLast Name
Designation*
Phone Number*

Country CodeArea CodePhone Number
Email*
example@example.com

Company Portfolio
Products/Services Provided*
Agency Experience*
Geographic Scope of Work*
Ports*
Potential Conflicts of Interest*

YesNo
Reason for Potential Conflicts of Interest
Browse Files
You can select multiple files. Only pdf, jpg, jpeg, png, docx, xlsx, msg, eml file types are allowed. Each must not exceed 4MB. Cancelof
Ownership Structure

Please insert the name, nationality and percentage of all parties holding more than a 5% interest in the company.
Details of Ownership*

Litigation Background
5a. Has your company or any subsidiary or affiliate of your company been the subject of past or pending litigation or government investigation?*

YesNo
5b. If your response is yes, please provide us with an explanation below.
6a. Has your company or any subsidiary or affiliate of your company, or any owner, officer, director, or employee of the company ever been the subject of a criminal investigation, indictment or a similar proceeding?*

YesNo
6b. If your response is yes, please provide us with an explanation below.
7a. Has your company, or any owner, director, or employee of company ever been the subject of a dishonorable discharge or dismissal, from a military organisation or other government office?*

YesNo
7b. If your response is yes, please provide us with an explanation below.
Business Insurance
Does your company have insurance certificates?*

YesNo
Insurance Provider*
Coverage Type*
Policy No.*
Currency Code*
Liability Value*
Exp. / Renewal Date*

DayMonthYear
Date
Attach Files
Please upload a copy of your certificate of entry. Only pdf, jpg, jpeg, png, docx, xlsx, msg, eml file types are allowed. Each must not exceed 4MB. Cancelof