Questionnaire

1. General Information

1.1 Company name of legal entity

Company

Address

Street

City

Postal Code

Country

Phone number

Tax Identification Number

Trade Register Number

Legal form

1.2 Contact person

First Name

Last Name

Position

Phone

Full address

Fax

1.3 Agent of another company

In case you are an intermediary or an agent of another company please provide their legal name and full address including country of that supplier/client

Name of legal entity

Full address

Contact person

1.4 Intended business relation: content and scope

Please select from the list products that your company is interested in.

Products

Please include more (technical) details about the products you are interested in:

1.5 Please indicate your business area of operation:

Please indicate the list of business modes in which your company is active in relation with the products your are interested. If you have selected various boxes, please add your comments per each:

Type of business mode

Which product from the ones indicated above

End User

Trader

Reseller

Retailer

Optional: Please include more details if necessary:

Area of Business/Country/Region

Anticipated business volume ($)

2. Client’s Information

2.1 Which of your company’s directors and employees will be authorized to represent and/or sign binding documents for the company? Please provide full names and positions.

Representatives (key accounts only):

2.2 Was there any renaming of your company name during the past years?

If yes, please provide further information:

2.3 Which are the intermediate and ultimate shareholders/owners (Ultimate Beneficiary-individual/individuals who owns or controls ultimately a legal entity through ownership, directly or indirectly , the whole package of shares or a number of shares or voting rights large enough to ensure control over that legal entity) of your company?

Intermediate shareholder(s):
Please provide full names of legal entities and location of headquarter (city, country)

Ultimate shareholder(s)( Ultimate Beneficiary):

2.4 In the past years and at present, has your company or controlled subsidiaries, one of its owners or management been subject to conviction (irrevocable court decisions) regarding corruption/bribery, money laundering, fraud, or other white-collar crimes or intentional violation of antitrust laws?

If yes, please provide further information:

2.5 Is there a possible conflict of interest on side of your company that might affect the business relation with the IEORT Innovative Group?

Spouse and 1st or 2nd degree relatives of, or your company‘s owners, management or authorized employees working for IEORT Innovative Group

Conflicting sideline jobs or sideline businesses of your company‘s owners or representatives

Former employees of IEORT Innovative are currently your company's employees and they are able to influence decisions concerning the intended business relation

If yes, please list the name(s) and position(s) below:

2.6 Is there any litigation that might have an adverse effect to its business?

If yes, please provide further information below:

The company is requested to provide an excerpt issued by a certified authority of the country where the company is registered no older than 30 days (e.g. Trade Registry in Romania) for to include information related with the current status of the company (in activity, dissolution, insolvency, bankruptcy) and registration information (company main activities, ownership, existence of declared Representative Office address and authenticity of the Legal Representative, management).

2.7 Does your company require to have any valid mandatory licenses for running certain activity related to the indicated business interest?

If yes, further information about which kind of licenses is required:

2.8. Any additional relevant information about your company (e.g. how did you come across IEORT Innovative Group; information regarding pap collaboration between your company and IEORT Innovative Group entities; information about your company’s management, shareholders and their collaboration with other companies within IEORT Innovative Group):

Statement of the data subject and consent of the data subject for data processing

In addition, I declare that I agree to the following data processing operations, based on my consent according to Art. 6 para. 1) letter a) of the General Data Protection Regulation, as follows:

For direct marketing purposes on sms, email, fax, phone calls in order to receive newsletters and other commercial communications in accordance with paragraph 2, letter (a) from Privacy Statement (section “Purposes of personal data processing”):

Yes

For profiling purposes in order to receive customised offers in accordance with paragraph 2, letter (b) from Privacy Statement (section “Purposes of personal data processing”):

Yes

For the purpose of being informed about the events organised by the Controller and the KMG Innovative Environmental Oil Refinery Group entities, to be invited in such events, by sms, email, fax, phone communications, in accordance with paragraph 2, letter (c) from Privacy Statement (section “Purposes of personal data processing”):

Yes

I give my consent to the processing of my personal data for the above purposes freely and specifically, after being fully informed of the processing operations to which I have given my consent.

I agree with the terms and conditions of the privacy statement