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SCHEDULE 5

CONSULTANT INFORMATION QUESTIONNAIRE
(To be completed by Applicant)


This Information Questionnaire is intended to collect information from a proposed or existing consultant (“the Applicant”) that provides or is being considered to provide consulting services to PMI outside the U.S. for the purpose of determining whether the Applicant’s engagement, retention and conduct of business on behalf of PMI complies with PMI’s corporate policies and applicable laws. Chief among such laws is the United States Foreign Corrupt Practices Act (the “FCPA”).

Upon completion and execution of this Information Questionnaire, please return it to the PMI person with whom you are in contact. Please complete the Information Questionnaire as completely and accurately as possible. Please feel free to attach additional pages as necessary to answer completely.

BASIC INFORMATION ABOUT APPLICANT
  1. Contact Details:
    1. Full legal name:
    2. Other assumed names or business names:
    3. Business address for Applicant headquarters:
    4. Telephone:
    5. Email and Applicant website (if applicable):
    6. Business address, telephone numbers, and email address for principal office of Applicant in Territory:
  2. Function of Applicant organization, e.g., investigative services, market research, etc. Please include a description of the services Applicant will provide for PMI:
  3. Information on ownership and management of Applicant:
    1. Is the Applicant an individual, partnership or incorporated entity?
    2. Who are the partners, members of the Board of Directors, controlling shareholders, and/or beneficial owners of the Applicant?
    3. Who are the principals of the Applicant (partners, directors, officers, significant employees) who may be providing substantial services to PMI?
    4. Does any person, entity or agency not listed above have any management or other controlling interest in the Applicant’s business? If so, what forms the basis of such interest?
    5. Have any of the persons listed in 3 (b) to (d) above held a position in any government, including, but not limited to, civil service (including any government agencies or ministries such as customs), the police, or the military? If so, who?
    6. Does Applicant engage any third parties who may provide services to or on behalf of PMI with respect to applications to or requests from Government Officials?


    (Please attach a copy of resume or biographical/professional synopsis of each principal, partner, controlling shareholder, director, officer, and/or significant employee who will provide substantial services to PMI, including such information as education and business experience.)

  4. Formation and registration of Applicant:
    1. Date of incorporation/formation (attach certificate of incorporation):
    2. Commercial Registration, Number/Business License or Registration (attach registration certificate):
  5. Names and addresses of Affiliated Companies (parent, subsidiary, sister companies):
  6. Number of employees:
    Functions:
    1. How long in present business:
    2. Other lines of business and length of time in each:
  7. Brief description of facilities and offices:
  8. Past experience in providing services similar to those contemplated in the Master Consulting Services Agreement:

FINANCIAL INFORMATION
  1. Approximate annual revenues of Applicant:




REFERENCES

  1. Bank and Credit References:

  2.   Name of Bank or Credit Institution Address Name of Contact Phone No. Email
    1          
    2          
    3          
    4          


  3. Personal references who may be contacted (i.e. persons who are knowledgeable about the personal, professional, business reputation, and abilities of the Applicant):

      Name Address Phone No. Email
    1        
    2        
    3        
    4        
  4. Business References
    1. List other companies represented presently and in the last five years:

        Name of Bank or Credit Institution Address Name of Contact Phone No. Email
      1          
      2          
      3          
      4          


    2. List other references who are acquainted with the business and reputation of the Applicant:

        Name of Bank or Credit Institution Address Name of Contact Phone No. Email
      1          
      2          
      3          
      4          
  5. Other public references (e.g., listing in trade journal):


CONFLICT OF INTEREST/COMPETITIVE INFORMATION

    1. Have you served as, or are you presently, consultant or contractor to a competitor or potential competitor, of PMI or any affiliates of PMI?

      Yes __________ No __________

      If yes, describe (include names and explanation):

    2. Do you currently employ, or have you associated in any business capacity with, a person previously employed by PMI or any affiliates of PMI?

      Yes __________ No __________

      If yes, describe (include names and explanation):

    3. Will such person, formerly employed by PMI or any affiliates of PMI, be engaged in an activity on your behalf relating to your representation of PMI?

      Yes __________ No __________

      If yes, describe (include names and explanation):


FCPA INFORMATION

The term “Government Official” means any officer or employee of, or person acting on behalf of (i) a government or one or more of its department, agencies, or Government Instrumentalities, or (ii) a Public International Organization; or any official party or candidates for political office. If you are not sure if someone is government official, please consult with your Applicant Sponsor (representative of PMI who is proposing your engagement or retention on behalf of PMI). Note that in some contexts, interactions with close family members of a Government Official may be treated as interaction with that Government Official.

    1. Are any of your employees who will negotiate the agreement with PMI or render substantial services to PMI, or any of your officers, directors, controlling shareholders or owners, currently, or have they been “Government Officials” (as defined above)?

      Yes __________ No __________
    2. Do any of your employees who will negotiate the agreement with PMI or render substantial services to the PMI, or any of your officers, directors, controlling shareholders or owners, have currently, or have they had close family, business, or other ties with “Government Officials” (as defined above)?

      Yes __________ No __________
    3. Does Applicant provide any benefit (payments, loans, etc.) to “Government Officials”, (as defined above)?

      Yes __________ No __________

      If Applicant provides any benefit to “Government Officials” in what form and frequency is such benefit provided?




If the answer to question 16 (a) and/or 16 (b) is yes, please provide the following information (if the subject person has close family, business or other ties with Government Official, answer (a) through (d) and (h) with regard to that person, and (a) and (e) through (g) with regard to the Government Official)
  1. Name and address of person:
  2. Position in or relationship to Applicant:
  3. Percentage of ownership or voting power in Applicant:
  4. Authority to contract for, execute documents, agreements, or instruments on behalf of Applicant:
  5. Positions held in Public International Organization, government, or department, agency or instrumentality thereof, or political party:
  6. Time periods during which such positions were held in a Public International Organization, government, or department, agency or instrumentality thereof, or political party:
  7. Description of duties of such person when in the service of Public International Organization, government, or department, agency or instrumentality thereof, or political party:
  8. If the subject person has close family, business or other ties with a Government Official, state the nature of those ties:


  1. Are you familiar with the prohibitions of the FCPA (as defined above)?

    Yes __________ No __________

  2. Have you previously been accused by anyone of violating the FCPA or engaging in any practice which would be deemed to be the making of an improper payment to a Government Official, or have you been the subject of any anti-corruption probe or investigation? (If so, please explain)

    Yes __________ No __________

    If yes, describe (include names and explanation):

OTHER

  1. Provide any other information you may wish to add relating to anti-corruption compliance or the interests of PMI:
  2. Does Applicant have an anti-corruption compliance program? (If so, please describe the program.)


Name, address, and telephone number of Applicant Sponsor:




APPLICANT (Applicant/Consultant): ______________________________ [print name of Applicant]

The person whose signature appears below is authorized to certify on behalf of Applicant that the foregoing is true and correct. The information provided above is, to the best of my knowledge and belief, accurate, current, and complete. I agree to notify PMI promptly of any material changes to the information provided herein.

Signature: ____________________________

Print Name: ____________________________

Title: ____________________________

Date: ____________________________

DOCUMENTS TO BE RETURNED BY APPLICANT ALONG WITH THE COMPLETED CONSULTANT INFORMATION QUESTIONNAIRE:

  1. Copy of a curriculum vitae or biographical/professional synopsis of any person listed in Question 3, including such information as education or business experience
  2. Certificate of incorporation, if applicable
  3. Registration Certificate, if applicable
  4. Any additional documentation needed to answer Questions 15, 16 & 18
  5. Release (attached)