8-FCPA Disclosure Statement.pdf

FCPA DISCLOSURE STATEMENT

Foreign Corrupt Practices Act Disclosure Statement by Applicant Wishing to Serve as an Agent or Consultant for the

Dallas/Fort Worth International Airport

As part of its compliance program for the United States Foreign Corrupt Practices Act (“FCPA”), the Dallas Fort Worth International Airport Board (the “Airport”) requires that all applicants (hereinafter referred to as the “Applicant”) wishing to be considered for retention as an agent or consultant for the Airport in locations outside the United States, provide the following information.

1. General Information

a. Full name of Applicant:

b. Complete business address:

Telephone number:

Facsimile number:

Mobile number:

c. Indicate type of business organization of Applicant:

Individual acting as a Sole Proprietorship Corporation Partnership Limited Liability Company Other business entity (please describe type): _______________________

d. Country or Countries where Applicant seeks to represent the Airport:

1st 2nd 3rd

(i) Is registry with a Government Authority a requirement for Applicant to conduct of business in the Country?

1st Yes No 2nd Yes No 3rd Yes No

(ii) If above is “yes”, is Applicant registered? If “yes”, provide registration or tax number

Yes No Registration or Tax Number 1st 2nd 3rd

2. Has Applicant ever provided services for the Airport?

Yes No

3. Has Applicant represented other clients with respect to the conduct of a similar business within the Country?

If “yes”, please list all such former or present clients:

4. Has Applicant, any employees of the Applicant or any director or owner of the Applicant ever been the subject of an investigation or criminal law violations, or been convicted of a crime?

If “yes”, please give details below:

5. Please list all current and former directors and officers of Applicant (if a business) and all current and former employees of Applicant (if Applicant has fewer than 10 employees):

6. Please list every former or current owner of Applicant (and indicate their period of ownership if a former owner):

7. Please list every company or other business entity which is affiliated with Applicant (an affiliate is a company that Applicant owns at least 10% of):

8. If Applicant is a company, then has any owner, director, officer or employee (former or current) of Applicant served in a salaried or appointive position within the Government of the Country?

Yes No

9. Indicated below whether or not the following is a correct statement (for individual Applicants).

Neither Applicant, Applicant’s spouse, nor any member of Applicant’s or Applicant’s spouse’s family, is now serving, or ever has served, in a salaried or appointive position within the Government of the Country?

Correct: Not Correct:

If “Not Correct” was selected, please provide details:

10. Has Applicant ever conducted business under an alias, assumed name, trade name or used any other business name other than the full business name listed above?

Yes No

If “yes”, please list the other names below:

11. If Applicant is an individual, please list:

(a) Every other business for which Applicant is now, or ever has been employed:

(b) Every publicly-traded company in which Applicant owns more than a 5% ownership interest:

(c) Every non publicly-traded company or other business entity in which Applicant holds an ownership interest:

12. Please list THREE unaffiliated business contacts, and at least one banking institution contact, which the Airport may contact for reference purposes for Applicant:

Business Contacts

Name:

Business Relationship:

Address

Telephone number:

Mobile number:

Name:

Business Relationship:

Address

Telephone number:

Mobile number:

Name:

Business Relationship:

Address

Telephone number:

Mobile number:

Banking Contact

Name:

Business Relationship:

Address

Telephone number:

Mobile number:

13. Are you familiar with the prohibitions of the United States Foreign Corrupt Practices Act?

Yes No

14. Have you previously been accused of violating the United States Foreign Corrupt Practices Act or engaging in any practice which would be deemed to be the making of an improper payment to a public official?

If so, please explain:

15. Full name of person completing this form for Applicant:

Signature: __________________________________________

Name: _____________________________________________

Title/Designation: _____________________________________

Telephone Number: ___________________________________

Date:_______________________________________________