HAITI EARNED IMPORT ALLOWANCE PROGRAM
TRANSACTION FORM

Type of Transaction:





For all transactions, please provide the following information about your company:


COMPANY NAME
IMPORTER OF RECORD NUMBER
CONTACT PERSON(S):
ADDRESS:
TELEPHONE NUMBER:
FAX NUMBER (if available):
EMAIL ADDRESS:
WEBSITE (if available)
HOW IS APPLICANT QUALIFIED?



LIST OF SUPPORTING DOCUMENTS CONTAINED IN ATTACHED FILES:

(only Adobe Acrobat and Microsoft Word files are accepted)

NOTE: If the online system does not accept your file, either due to size or formatting issues, please contact OTEXA at (202) 482-3400 for assistance.




I HEREBY AFFIRM THAT THE INFORMATION CONTAINED IN THIS TRANSACTION REQUEST IS ACCURATE. I UNDERSTAND THAT OTEXA MAY, AT ANY TIME, INDEPENDENTLY VERIFY THE INFORMATION THAT I HAVE SUBMITTED ABOVE. I ALSO UNDERSTAND THAT OTEXA MAY ESTABLISH AND IMPOSE PENALTIES FOR THE SUBMISSION OF FRAUDULENT INFORMATION UNDER THIS PROGRAM, OTHER THAN A CLAIM UNDER THE CUSTOMS LAWS OF THE UNITED STATES OR UNDER TITLE 18, UNITED STATES CODE.


Submitted by:


NAME OF REQUESTOR
DATE