Members of
the Board of Directors, Senior Officers, Partners, and Owners:
If
“Organization Type” is “Corporation”,
“Limited Liability Company”, or “Partnership”
then only display following options
:
Yes ☐
No ☐ Chief
Executive Officer
Yes ☐
No ☐ President
Yes ☐
No ☐ Chief
Financial Officer
Yes ☐
No ☐ Chief
Operating Officer
Yes ☐
No ☐ Chief
Information Officer
Yes ☐
No ☐ Chief
Technology Officer
Yes ☐
No ☐ Corporate
Secretary
Yes ☐
No ☐ Partner
[number of Partners __ ]
Yes ☐
No ☐ Managing
Member
Yes ☐
No ☐ Treasurer
Yes ☐
No ☐ Inside
General Counsel
Yes ☐
No ☐ Chairman
of the Board of Directors
Yes ☐
No ☐ Member
Board of Directors [ number of inside positions __ ]
Yes☐
No ☐ Owner
(Natural Person) [number of Owners (Natural Person) ___ ]
Yes ☐
No ☐ Owner
(Legal Entity) [number of Owners (Legal Entities) ___ ]
Yes☐
No ☐ Owner
(Trust) and managing Trustee [number of Trusts and managing
Trustees ___]
Yes ☐
No ☐ Other
[number of other positions __ ]
If
“Organization Type” is “Educational
Institution” then only display the following options:
Yes ☐
No ☐ Provost
Yes ☐
No ☐ Chancellor
Yes ☐
No ☐ Chief
Executive Officer
Yes ☐
No ☐ President
Yes ☐
No ☐ Chief
Financial Officer
Yes ☐
No ☐ Chief
Operating Officer
Yes ☐
No ☐ Chief
Information Officer
Yes ☐
No ☐ Chief
Technology Officer
Yes ☐
No ☐ Corporate
Secretary
Yes ☐
No ☐ Partner
[number of Partners __ ]
Yes ☐
No ☐ Managing
Member
Yes ☐
No ☐ Treasurer
Yes ☐
No ☐ Inside
General Counsel
Yes ☐
No ☐ Chairman
of the Board of Directors
Yes ☐
No ☐ Member
Board of Directors [ number of inside positions [__ ]
Yes☐
No ☐ Owner
(Trust) and managing Trustee [number of Trusts and managing
Trustees ___]
Yes ☐
No ☐ Owner
(Legal Entity) [number of Owners (Legal Entities) ___ ]
Yes☐
No ☐ Owner
(Natural Person) ) [number of Owners (Natural Person) ___ ]
Yes ☐
No ☐ Other
[number of other positions __ ]
If
“Organization Type”
is “Sole Proprietor” then only display the following
option:
Yes ☐
No ☐ Sole
Proprietor
If
“Organization Type” is” Individual” then
only display the following option.
Yes ☐
No ☐ Individual
If
“Organization Type” is “U.S. Government”
then only display the following option.
Yes ☐
No ☐ U.S.
Government Official
If
“Registration Type” is “Foreign Government”
then only display the following option.
Yes ☐
No ☐ Foreign
Government Official
Complete the below for all
Position(s)/Title(s) where selected Yes above.
Member Type:
☐ Natural Person ☐
Entity
U.S. Person:
☐ Yes ☐
No
List all Position(s)/Title(s)
Held: ________________
Other:
__________________________________
If
applicant selects “Owner (Trust),” or “Owner
(Legal Entity)” or “Owner (Natural Person)” in
response to “List all Position(s)/Title(s),” then
display and require responses to the following fields:
Does the
owner own more than 5% of the applicant’s voting
securities? ☐ Yes
☐ No
Does the
owner own more than 50% of the applicant’s voting
securities? ☐ Yes
☐ No
Does the
owner have the authority or ability to establish or direct the
general policies or day-to-day operations of the applicant? ☐
Yes ☐ No
If
applicant selects “Natural Person” in response to
“Member Type,” then display and require completion
of the following fields:
Last Name:
________________________________
First Name:
________________________________ Date of Birth:
_______________________
Middle Name:
______________________________ Birth Country:
______________________
Citizenship(s):
_____________________ _Add
_
Country of Residence: ________________
Telephone:
_________________________
E-Mail:
____________________________
If the
applicant selects “Member Type” is a natural person
and selects yes to “U.S. Person”, and the applicant
and Members list a residence outside of the United States, then
display the following question:
Summarize how U.S. Person
Members residing outside the United States exercise the
authority or the ability to establish or direct the general
policies or day-to-day operations of the Applicant, its
subsidiaries, and its controlled affiliates, to ensure ITAR
compliance and oversight?
If
applicant selects “Entity” in response to “Member
Type,” then display and require completion of the
following fields:
Company/Organization Name:
_________________
Doing Business As Name:
_____________________
Address Line:
_____________________________
City: ___________________________
Country:_________________________
Zip/Postal Code:
__________________
If
applicant selects “Owner (Trust)” in response to
“Organization Type” then display and require
completion of the following fields:
Trust Information
Trust
Name:________________________________
Address
Line:_______________________________
City:
______________________________________
Country:
__________________________________
Zip/Postal Code:
____________________________
Trustee Information
Last Name:
________________________________
First Name:
________________________________ Date of Birth:
_______________________
Middle Name:
______________________________ Birth Country:
______________________
Citizenship(s):
_____________________ _Add
_
Country of Residence: ________________
Telephone:
_________________________
E-Mail:
____________________________
Point of Contact:
First Name:_______________________
Last Name: _______________________
Telephone: _______________________
Email: _______________________
Type of Modification:
☐ No change ☐
Substantive Change ☐
Merger ☐
Acquisition ☐Divestiture
☐Remove/not dispose
☐
Establishment/Addition (non-MAD) ☐Other
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