INTERMEDIARY QUESTIONNAIRE
代理商问卷调查
Category P1
This questionnaire is a critical part due diligence process related to complia nce with anti‐bribery laws in and elsewhere. Please answer all applicable questions and promptly return this questionnaire to its sender. Completion of this questionnaire is required for your Company’s continued or future relationship with any CLARCOR company. Please attach additional information if necessary to fully complete this questionnaire.
此问卷调查为)尽职调查流程中很关键的一部分,遵守某国及其他地区的反腐败法规.请回答相关的问题并尽快回传.如想和任何子公司继续或开展合作的请填写这份问卷调查,另外请附上问卷要求提供的相关附件.
Thank you for your cooperation.
谢谢您的合作.
SECTION A: BUSINESS INFORMA TION
A部分:企业信息
1.General Information:
一般信息:
Registered Company Name注册公司名称: Street Address地址: _
City城市: __ ___ State/Province省份: __ _ __
Country国家: __ _ ___ Postal Code邮政编码: __ _
Office Telephone公司电话: __ __
Website Address公司网站: __ __
Contact Person联系人: __ __ Email邮箱: _ _ _
Date Company was Established:公司成立时间: __ _
Number of Employees:员工人数: ___ __
2. Which of the following best describes your company?
贵公司属于以下哪种公司?
Individual/Sole Proprietor 个体所有者/独资企业主Private Company 民营企业------
Public Company 上市公司
Other 其他: __ ____
3. Your company’s primary industry:
贵公司主营业务:
Construction 建筑Engineering工程Defense/Aerospace国防/航空
Filtration 过滤Manufacturing制造Oil / Gas / Energy石油/天然气/能源
Transportation 交通运输Other其他: ____________________________________
4. Your company’s current or pending relationship with a CLARCOR company:
贵公司现在或者将来与我公司的关系:
Consultant咨询顾问Distributor代理商sales Agent销售代表
Supplier供应商Other其他: ____________________________________
5. Will your company engage any other third party (e.g., consultant, sales agent, etc.) to assist in your company’s business relationship with the CLARCOR company?
贵公司会雇佣任何第三方机构 (例如:咨询顾问公司,销售代理等) 来帮助销售产品吗?
No 否 Yes 是
If yes, describe their involvement:
如选是,请描述他们是怎么参与的 : -----------------------------------------------------------------
6. Identify the countries where your company does business:
请指出贵公司在那些国家从事业务: _______国外没有业绩,目前仅限于国内____.
7. Does your company have any subsidiary organizations?
贵公司有子公司吗?
No 否 Yes 是
(If yes, complete the following for each subsidiary)
(如有,请完善以下子公司信息 )
Name公司名称:
_______________________________________________________________________________ Address地址:
_____________________________________________________________________________
City城市:
_________________________________________________________________________________ State/Province省:
________________________________________________________________________
Country国家:
_____________________________________________________________________________ Postal Code邮政编码:
__________________________________________________________________________
Office Telephone公司电话:
______________________________________________________________________
8. Is your company part of any joint ventures?
贵公司有合资成分吗?
No 否 Yes 是
(If yes, complete the following)
(如是,请按如下填写)
Name of Joint Venture合资企业名
称:__________________________________________________________________
Address地址:
_____________________________________________________________________________ City城市:
_________________________________________________________________________________ State/Province省:
________________________________________________________________________ Country国家:
_____________________________________________________________________________ Postal Code邮政编码:
__________________________________________________________________________
Office Telephone公司电话:
______________________________________________________________________
Primary Industry of Joint Venture合资企业主营业务:
_________________________________________________________
9. Please provide background information on your company’s expertise and business activities. Include a brochure or recent annual report, if available.（填写业务范围即可）
请提供公司专营业务活动的资质和背景资料,可以的话请提供样本资料或最近的年度报告.
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
SECTION B: REFERENCE INFORMA TION
B部分:参考信息
1. Provide two external business references with whom CLARCOR may inquire if it chooses.
请提供两个贵公司业务上往来的公司,日后查询.（填写不重复的供应商信息）
2. Will your company provide a recent audited financial statement?
贵公司愿意提供最近的经审计的财务报表吗?
No 否 Yes 是
如果没有,请提供一份可供公司以后查询贵公司财务状况稳定性的财务参考资料,例如银行,供应商信息等. （请提供除了B部分问题1中第三个供应商的资料）
SECTION C: INFORMA TION A BOUT “KEY PEOPLE”
C部分:”主要负责人”信息
1.List all owners, partners or shareholders of your company (percentage should total 100%). Include
any government ownership. You may skip this question if your company is publicly held. However, if your company is publicly held and you know that some of its shares are owned or controlled by a government or government entity, please identify the government or government entity.
请列出贵公司的所有人, 合伙人或者股东 (按总为 100%股份比例). 包括任何国有成分.如果您公司是上市公司可以跳过这个问题. 但是,如果您知道公司有部分股份是国有的或者是政府单位所有的,请指出.（只需填写持股人信息）
2.List the individuals on your company’s Board of Directors.
请列出公司董事会的成员.
3. List all company managers who will interact with the company or assist in the sale of its products:
Please provide a resume or short biographical background for all of the “Key People” listed above in this Section C (i.e., all non‐entity owners, partners or shareholders, members of the Bo ard of Directors and all company employees who will interact with the company or assist in the sale of its products).
请提供C 部分上出现的”主要负责人”的一份简短简历(例如:所有企业主,合伙人或者股东,董事会成员和所有负责销售Clarcor 产品的公司员工)
4. Have any of the Key People listed above held a job in the last 5 years with the government, any
government agency (including the military) or any government owned or government controlled entity? 在过去的五年里,上面列出的”主要负责人”有否在政府,政府机关(包括军队)或者任何国有企业或国
有控股企业工作过吗?
No 否 Yes 是
(如果有,请填写下面的信息)
5. Do any of the Key People provide any services to or have or seek any business with a government, any government agency (including the military) or any government owned or government controlled entity? 这些”主要负责人”是否曾经或正在从事与任何政府,政府机关(包括军队),国有企业或者国有控股企业的商务往来?
No 否 Yes (Complete chart below)是(请填写下面表格)
6. Do any of the Key People currently hold any position with or have any substantial duties for any
political party or political campaign?
“主要负责人”有否在任何政党里任职或担任重要职位?
No 否Yes(Complete chart below)是(请完成下面表格)
7. Are any of the Key People a candidate for any political office?
“主要负责人”里面有是政党候选人吗?
No 否Yes (Complete chart below)是(请完成下面表格)
8. Are any close relatives of any of the Key People:
“主要负责人”的亲属里面有没有:
a)Employed or otherwise engaged in any capacity by a government, any government agency
(includingthe military) or any government owned or government controlled entity?
在任何政府,政府机关(包括军队)或者国有企业和国有控股企业里面任职或从事工作?
No 否Yes是
b) Hold any position with or have substantial duties for any political party or political campaign?
在任何政党里任职或担任重要职位?
No 否Yes是
c) A candidate for any political office?
是政党候选人?
No 否 Yes是
(If “yes” to one or more of these questions, please complete the information below)
9. Will your company soli cit or assist in the sale of the company’s products to a government, any government agency (including the military) or any government owned or government controlled entity? 您公司会帮助销售公司的产品给政府,任何政府机关(包括军队),或者国有企业和国有控股企业吗?
No 否Yes是
(If yes, identify each potential purchaser)
(如果回答”是”,请把潜在的购买方详细指出)
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ SECTION D: COMPLIA NCE INFORMA TION
D部分:合规信息
1.Does your company currently have a written policy addressing bribery?
您公司现在有返贿赂的明文规定吗?
No 否 Yes (please provide a copy)是(请提供一份附件)
2. Please respond to the following questions on behalf of your company and all Key People listed in Section C. Please provide an explanation if the answer to any question is “yes.”
请代表贵公司及所有C部分列出的”主要负责人”回应下面的问题.请对答案为”是”的答案进行解释说明.
a) Has your company or any of the Key People ever been charged or convicted as part of any
investigation or litigation involving (i) bribery, fraud or corruption, (ii) securities or
commodities trading laws, or (iii)anti‐trust or anti‐competition laws?
您公司或任何”主要负责人”曾经被调查或起诉涉嫌(i)贿赂,商业诈骗或者腐败(ii)违反证券
或商品贸易法律(iii)违反反垄断和竞争法
No 否 Yes 是
b) Has your company or any of the Key People ever been ever been debarred from competing
for government contracts in any country?
No 否 Yes 是
______________________________________[Name of Company]公司名称
By: ___________________________________[Signature]签字
Name:_____________ [Print Name]
姓名
Title:_____ _____
职务
Date:_____ ___ 日期