Third Party Due Diligence Questionnaire

We are committed to compliance and conducting business with transparency and integrity.  Our reputation, like yours, is highly important and we have therefore adopted a standard due diligence process for third partiestem.   

Please complete this questionnaire in its entirety, responding to each question or request for information. Upon completion, please return this form along with the requested documents A-E (if requested documents do not exist, please indicate so) to:

xxxxxxxxxxxx

Any information provided through this questionnaire and/or originated during our due diligence process (“Confidential Information”) shall be treated confidentially.  We hereby agree to (i) keep such Confidential Information under strict confidentiality and use it exclusively for the purpose of the due diligence process; and (ii) allow access to such Confidential Information only to our employees who need to access to the same, for the purposes of the due diligence process, or to external counsel contracted specifically for such purpose, provided parties shall always be subject to a non-disclosure commitment.

Confidential Information shall not include any information which: (i) was known or in our possession before the date of its disclosure; (ii) is legitimately in or subsequently comes into the public domain or made available to the public in any way other than by breach by us or our  confidentiality obligations hereunder; (iii) has been rightfully received without restriction on disclosure or use from a third party, whom we reasonably believe to be authorized to make such disclosure; (iv) which the disclosure has been authorized in writing by the disclosing party; or (v) the disclosure is required by law or by virtue of a judicial, court or administrative order, provided that such disclosure is limited to the extent strictly necessary to comply with said order or legal requirement.

 For questions or clarifications, please contact:  xxxxxxx

 

 

Third Party Due Diligence Questionaire

Form Completion Information

Business Information

2b. Business Address
2b. Business Address
City
State/Province
Zip/Postal
Country
2c. Additional business location addresses from which COMPANY will be providing services
2c. Additional business location addresses from which COMPANY will be providing services
City
State/Province
Zip/Postal
Country

If COMPANY is an individual, provide the following information:

Organizational information relating to COMPANY

Request A: Please provide a copy of certificate of incorporation, bylaws or equivalent organization document. (Upload multiple)
Maximum upload size: 2.1MB
3d. Ownership: i. Does any governmental or government entity hold equity interest in the COMPANY?
If yes, the governmental’s equity interest in the COMPANY is:
3d. Ownership ii) Does the COMPANY have shares listed on the stock exchange

4. Please provide the following business information relating to COMPANY:

Request B: Please provide a copy of any business brochures or annual report.
Maximum upload size: 2.1MB

5. Company Financials

Do you have financial statements?
Request C: please provide copies of most recent audited financial statements and the most recent unaudited and/or interim financial statements.
Maximum upload size: 2.1MB

Reference Information - provide external business reference

Reference 1 - Address
Reference 1 - Address
City
State/Province
Zip/Postal
Country

Reference Information - provide second external business reference

Reference 2 - Address
Reference 2 - Address
City
State/Province
Zip/Postal
Country

Personal Information - 1. Please list all partners, directors and/or greater than 10% owners/shareholders (COMPANY Leaders). Do not provide any information that may not be allowed under your applicable data

Please provide a biography and/or resume of leaders (If more than two, please include name and requested information in an attachment)
Maximum upload size: 2.1MB
File Upload
Maximum upload size: 2.1MB

2. Please list all employees who will interact with government officials or government owned companies, when working with us (COMPANY Employees).

If more than 2 employees interact with government officials or government owned companies upload in an attachment.
Maximum upload size: 2.1MB
3.Does any COMPANY Leader or COMPANY Employee hold or maintain additional ownership (more than a nominal amount), directorships and/or employment outside your primary business?
4. Has any COMPANY Leader or COMPANY Employee ever held a job in the government or was any COMPANY Leader or COMPANY Employee an officer in the military?
4e. (If more than one, please include name and requested information in an attachment)
Maximum upload size: 2.1MB
5. Are there any local laws applicable to any COMPANY Leader or COMPANY Employee which place restrictions on individuals after they leave public service?
6. Does any person, entity, government or government agency not listed as an COMPANY Leader or COMPANY Employee have any management right or financial interest (other than less than 10%/passive shareholder) in your business?
(If more than one, please include name in an attachment)
Maximum upload size: 2.1MB

Potential Conflicts Information

1. Does any COMPANY Leader or COMPANY Employee hold any position with or have any duties for any political party, political campaign or active candidate for political office?
(If more than one, please include name in an attachment)
Maximum upload size: 2.1MB
2a. Are any family members of any COMPANY Leader or COMPANY Employee employed or otherwise engaged in any capacity by any government or government controlled company, or serves as an officer in the military?
2b. Are any family members of any COMPANY Leader or COMPANY Employee employed by or have duties for any political party, campaign or is a candidate for political office?
3. Will the COMPANY, any COMPANY Leader or COMPANY Employee solicit business from any government agency or government controlled company?

Compliance Information

1. Does the COMPANY currently have a written policy addressing ethical business practices and the prevention of bribery?
Please upload copy of policy
Maximum upload size: 2.1MB
3. Please indicate preferred method of payment:
4. Has the COMPANY, any COMPANY Leader or COMPANY Employee ever been convicted of violating any rules or regulations governing the purchase or sale of goods or services?
5. Has the COMPANY, any COMPANY Leader or COMPANY Employee ever been found guilty of violating any law governing donations, contributions, honoraria, or any other form of remuneration to any government official?
6. Has the COMPANY, any COMPANY Leader or COMPANY Employee ever been found guilty of any violations of anticorruption, securities, trading or tax laws?
7. Has the COMPANY, any COMPANY Leader or COMPANY Employee ever been deposed or subpoenaed in connection with any litigation or investigation involving any law governing donations, contributions, honoraria, or any other form of remuneration to any government official?
8. Has the COMPANY, any COMPANY Leader or COMPANY Employee ever been deposed, subpoenaed or asked to testify before any legislative body concerning fraud or abuse with regard to the purchase or sale of goods or services?
9. Has the COMPANY, any COMPANY Leader or COMPANY Employee ever been found guilty of any violations of laws governing the regulation of antitrust practices or been deposed or subpoenaed in connection with any litigation or investigation involving such laws?
10. Has the COMPANY, any COMPANY Leader or COMPANY Employee ever been mentioned by name in the press (i.e. article in newspaper, magazine or online vehicles) as having violated anti-corruption or anti-trust laws?
11. Has the COMPANY, or any company in which your company owns more than a 10% interest ever been disbarred from competing for World Bank contracts?
12. Has the COMPANY or any COMPANY Leader ever been the subject of any voluntary or involuntary bankruptcy or other similar proceeding?

13. Is the COMPANY, any COMPANY Leader or COMPANY Employee currently named on any of the following lists?

13a. The Specially Designated Nationals List (SDN):
13b. The Specially Designated Global Terrorist List:
13c. The Specially Designated Narcotics Traffickers List or Kingpin List:
13d. Any U.S., EU, or other country or region Denied Party Lists:

SUB-AGENT INFORMATION

SIGNATURE AND CERTIFICATION

I HEREBY DECLARE THAT THE INFORMATION PROVIDED HEREIN IS, TO THE BEST OF MY CURRENT KNOWLEDGE AND BELIEF, ACCURATE, UPDATED AND COMPLETE. I HEREBY DULY AUTHORIZE YOUR COMPANY AND/OR ITS REPRESENTATIVES AND/OR ITS AGENTS, FOR THE PERIOD OF 180 DAYS, TO VERIFY THE INFORMATION PROVIDED HEREIN, INCLUDING ALL REFERENCES; CRIMINAL AND/OR COURT RECORDS; CONDUCT AND/OR CONTRACT INVESTIGATIVE REPORTS WHICH CAN INCLUDE CREDIT STANDING, CREDIT CAPACITY, CHARACTER AND/OR GENERAL REPUTATION, EDUCATION BACKGROUND, EMPLOYMENT/WORK HISTORY AND CREDIT HISTORY, AMONG OTHERS AND HEREBY HOLD HARMLESS ALL OF THE PERSONS AND AGENCIES PROVIDING SUCH INFORMATION FROM ANY AND ALL CLAIMS AND DAMAGES CONNECTED WITH THEIR RELEASE OF INFORMATION. I HEREBY AGREE TO PROMPTLY INFORM YOU REGARDING ANY MATERIAL CHANGE TO THE INFORMATION PROVIDED, UNTIL THE EXECUTION OF THE RELATED AGREEMENT IN CONNECTION WITH THE BUSINESS RELATIONSHIP INTENDED BETWEEN THE PARTIES. I HEREBY ACKNOWLEDGE THAT THIS QUESTIONNAIRE WILL BE DEEMED TO BE DULY EXECUTED BY MY COMPLETING THIS FORM, AND EITHER ELECTRONICALLY TYPING IN MY NAME ON THE SIGNATURE LINE, OR PRINTING, SIGNING AND SENDING BACK A COMPLETED FORM.