Third Party Questionnaire
MIQ Logistics and its subsidiary and affiliate companies (“MIQ Logistics” or the “Company”) are
required and committed to comply with U.S. and non-U.S. laws applicable to the Company’s worldwide operations.
In furtherance of those legal obligations and as an initial step in our due diligence review process, please complete
the following questionnaire. Based on your response, the Company may request additional information about you
and your company. The Company may collect this information through additional written questions, in-person
interviews, or other means.
Please answer these questions as completely and accurately as possible. Where information is incomplete
or not ascertainable, please so state. For any answer requiring more space than is given in this questionnaire, please
attach the answer on a separate sheet of paper. Please attach all requested additional documents to this completed
response. The Company appreciates your assistance with this important process. Please contact Reid Schultz, the
Company’s Compliance Officer and General Counsel, at +1 913 906 6858, or by email at [email protected],
with any questions.
1. Identifying Information
a. Name of Company or Individual:____________________________________________________________
b. Other Names if any (e.g., d/b/a):
c. Business Address (principal place of business):
d. Phone #:
e. Fax: _________________________________________
g. webpage:_________________________________ h. Contact Person:
____________________
i Contact’s Title:____________________________ j. Contact’s Phone #:_ ____________________
k. Contact’s Email: _______________________________
2. Business Information
a. Please provide a copy of your commercial registration and/or incorporation charter documents, including
registration certificate for the country in which you are incorporated and in the country of intended activity,
if that is different from the country in which you are incorporated.
b. Number of employees: ____________________________________________________________________
c. Principal lines of business of company: _______________________________________________________
d. Other (non-principal) business activities, if any:________________________________________________
e. Other locations of business:
f. How long has the company been in operations?_________________________________________________
g. Approximate annual turnover/revenue in the last five years (check as appropriate):
_____ less than US$1 million, _____ US$1 to US$10 million,
_____ US$10 to US$50 million, _____ over US$50 million
h. What type of entity if the company? _________________________________________________________
i. Tax Identification #/Registration No.: ________________________________________________________
j. If company is a new venture, estimated turnover/revenue for next business
year:__________________________
k. Has your company or any of its principal officers, directors, or shareholders ever been charged with a
criminal offense? If so, provide details.
l.
Has the company’s registration ever been terminated voluntarily or involuntarily? If so, please provide and
explanation of the circumstances of the termination, and reinstatement, if any.
3. Ownership and Management
a.
If a company, are you publicly held?
YES
NO
If yes, what percent?
b. If yes, please attach a copy of your most recent public filing showing the company’s shareholders, partners, or owners; if
this filing does not list major (>5%) shareholders, please identify below the major shareholders (public and non-public). If
more space is needed, please attach to this questionnaire.
c. If no, please give (below) the names and nationalities of your principal shareholders (>5%), partners, or beneficial owners
below (If your direct owner is a company, list the ultimate beneficial owner and any intermediate entities or persons).
d. Please provide the following information about the owners/partners, as well as those employees who will perform services
under the proposed agency agreement or otherwise, on behalf of MIQ Logistics:
Name of Owner/Partner
Nationality
Percentage Ownership
Date of Acquisition of Interest
Do any other persons or entities hold an interest in the company’s equity, debt, revenues or profits, whether directly or indirectly?
YES
NO
Are any other persons or entities able to exercise control over the company through any other arrangement or relationship?
YES
NO
If yes to either question, please provide names and other details:
Please provide the following information about the Officers and Directors of the Company:
Name
Nationality
Title
Does any principal, owner, partner, director, officer or employee of the company or any affiliate currently hold any official office
with or have any duties, including any consulting, ceremonial positions, for any domestic or foreign government entity (including
public international organizations, agencies, subdivisions, wholly or partially state-owned enterprises, etc.), or any political party
or is any a candidate for any political office?
YES
If yes, please provide the following:
Name
Position(s) Held
NO
Government Entity or Political Party(ies)
Is any member of the immediate family of any of the principals, owners, partners, directors, officers or employees of the
company or any affiliate one or more of the following:
An official of any government/government agency?
YES
NO
An employee of any government/government agency?
YES
NO
An official of a political party?
A candidate for political office?
If yes, please providing the following:
Name
YES
YES
NO
NO
Position(s)/Office(s) Held
Familial Relationship
Is any principal, owner, partner, director, officer or employee of the company or any affiliate a former employee of any
government entity (including public international organizations, agencies, subdivisions, wholly or partially state-owned
enterprises, etc.)?
YES
NO
If yes, please provide the following:
Name
Position/Office Held
Government Entity
Dates of Employment
e. Do any of the persons listed in (d) above hold director, officer or other management positions with other companies or
entities? If yes, give the name of each company and the title of the relevant position.
f. Does your company use consultants or subcontractors?
YES
NO
If yes, please provide the following information:
Name of Consultant or
Subcontractor
Location
Contact
Information
Direct, Indirect, or Beneficial Interest by Foreign
Official in Consultant or Subcontractor
What is the contract or arrangement with each consultant or subcontractor or non-employee contractor?
What are your reasons for using consultants or subcontractors or non-employee contractors?
If any of these non-employee contractors has ties to government officials, officials of political parties or candidates for political
office, please identify the person, the office held or sought, proposed duties under this representation, and whether the office
relates to those duties.
g. Please provide the following information about any Joint Venture Partner with which your company is involved.
Name of Owner/Partner
4.
Nationality
Percentage Ownership
Date of Acquisition of Interest
References
a. Banking. Please provide the following information about the company’s banking relationships. Please also
provide a letter from a bank (on the bank’s letterhead) in which you have one or more business accounts, stating
that you are a customer in good standing and the length of time that you have had at least one account.
Principal Account (e.g., operating account)
Other Account
Other Account
Bank Name
Address
Phone
Fax
Contact Name
b. Financial Information. PLEASE INCLUDE IN YOUR RESPONSE A FINANCIAL STATEMENT OR ANNUAL REPORT
PERTAINING TO THE COMPANY WITH THIS RESPONSE.
c. Accountants/auditors. Please provide the name and contact information for the company’s outside accountants or auditors.
Will the company use any non-employee contractors to perform work for the Company?
YES
NO
If so, please describe:
d. Commercial. Commercial references (please give at least 3 references, including at least one U.S. company, if possible;
include contact name and telephone/fax information). The Company may contact some of your company’s past and/or present
business partners to obtain additional information about you/your company. For that purpose, please provide the following
information about past and/or present customers, affiliates, or business partners.
Name/title of individual
Contact address and telephone
Name of partner
Description of relationship
contact
And Email address
5. Foreign Corrupt Practices Act Compliance
Has your company or any affiliated entity ever offered, promised, or given anything of value directly or indirectly to a Foreign
Official or Covered Recipient?
YES
NO
If yes, please provide details including what was offered or given, to whom it was given, the reason that the Payment was
offered or made, the date the Payment was made, the location in which the Payment was made, and how your company became
aware of the Payment.
Have you ever received a request for payment, gift or kickback from any government official?
YES
NO
Have you ever been a party to a proceeding anywhere in the world for violation of applicable anti-bribery laws or regulations?
YES
NO
If yes to either of the above, please provide details below:
Are you familiar with and do you understand obligations under the U.S. Foreign Corrupt Practices Act (“FCPA”)?
YES
NO
Has your company or any associated or previously associated entity, any predecessor entity or any present or former owner,
manager, partner, director, officer, employee or consultant of your company been within the last ten years (10) years: (a)
suspended from doing business in any capacity; (b) charged or indicted with any criminal act; (c) the subject of any allegation or
investigation of fraud, bribery, misrepresentation or similar circumstances; (d) mentioned in the press for having been involved
in any improper activity; or (e) terminated by a client because of ethical or legal concerns?
YES
NO
If yes, please provide complete details including the entities, dates, and outcome or disposition.
6.
Certification: The undersigned entity hereby certifies that the information provided in this Questionnaire is true
and accurate to the best of our knowledge and belief. We also certify that if we learn of any additional information
that is relevant to this questionnaire, we will promptly report that information to Reid Schultz, MIQ Logistics’
Compliance Officer, at the address below. We acknowledge and agree we will be required from time to time to
certify to the Company regarding our compliance with the Company’s Policy, and the FCPA.
Name of Company:
By:
Printed Name:
Title:
Date: