Export Verification Form
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The sole purpose of our agency's existence is to help U.S. companies export and we need to know if we have helped you succeed!

The U.S. Department of Commerce, U.S. Commercial Service, Export Assistance Center of Philadelphia, PA, makes every effort to track the effectiveness of our international trade promotion programs by following up with companies that have taken advantage of our counseling, programs, or services.

We are very interested in learning about how effective our counseling and programs are and we would like to hear about your successes as a result of this activity.

In order to keep our agency in existence, we must report our activity to Congress and need to demonstrate that we work with real companies in real business situations. Reporting our performance lets us stay around to continue to assist you. We understand sensitivities regarding sales figures and are happy to receive generalized estimates or ranges. All sales information submitted will remain confidential and will not be made available outside of the U.S. Department of Commerce and U.S. Congress.

If you have any questions regarding this form or if you prefer to talk to us about your export success, please contact us at (215) 597-6101.

Thank you for taking the time to report your export success!
Fields marked with * are required.
OMB Control No.: 0625-0237
Expiration Date: 10/31/12

Contact Information

Company Name:*  
Salutation:  
Full Name:*  
Title:*  
Address:*  
City:*  
State:*  
Zip Code:*  
Telephone:      Ext.
Fax:  
Cell Phone:  
Email:*      Receive a Copy
Confirm Email:*  
Web Site:  


Company Profile  
Year company was established:*  
 

Type of company*:
 
Manufacturer
Distributor
Export trading company
Service
Other  

Sales Method:*
 
Direct
Agents
Distributors
Joint Venture
Other

*If you are not a manufacturer, do you or your firm have documented right to export the product or service?*
Yes    No    Not applicable  

*Is your product/service at least 51% U.S. content?
Yes    No  

Percentage export:
 

Total annual sales:*
 

Number of employees in the company:*
 

Do you have an export promotional budget?
Yes    No  

Please select your industry:*
 
 


Company Background*

 

 

Export Description
Did you make your first ever export sale in the past 12 months?*
Yes    No  

Have you appointed agents or distributors abroad?*
Yes    No  

Export experience/objective*
New to export
New to market
Increase to market
 

Countries you did export to*

Amount of export sale*
Please specify the approximate amount in USD (whole numbers only).

How did our office assist you?

 

  

Public reporting for this collection of information is estimated to be 5 minutes per response, including the time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection of information are voluntary, and will be provided confidentially to the extent allowed by law. Notwithstanding any other provision of law, no person is required to respond to, nor shall any 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 currently valid OMB control number. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Reports Clearance Officer, International Trade Administration, Department of Commerce, Room 4001, 14th and Constitution Avenue, N.W., Washington, D.C. 20230.