Exporter Company Registration Form

Exporter Company Registration Form

This form must be printed on your company headed paper and must be authorised by one of the following: Managing Director; Financial Director/Controller; Company Secretary or Chief Executive Officer.

* PLEASE NOTE: All fields marked with an asterisk are mandatory, if these are not completed we will return the application to you.

Exporter Company Details

If the business address differs from that registered with the Companies Registration Office (CRO), please attach a letter of explanation to include details of the address registered with the CRO.
Name*:
Address Line 1*:
Address Line 2:
Address Line 3:
County*:
Post Code (if Dublin): / Telephone Number*:
Fax Number:
Website Address:
CRO Number*:
VAT Number
(please provide if VAT registered):

Contact Details

Company Secretary* (this should correspond to the information held by the Companies Registration Office)

/

Manager with Responsibility for Trade Compliance* (this is normally a senior manager in the company)

Name*:
Email*:
Phone*: / Name*:
Email*:
Phone*:

Authorised Officer Contact Details

(We recommend that you nominate at lease 2 authorised officers. 3 is the maximum number that can be nominated)

Authorised Officer 1*

/

Authorised Officer 2

/

Authorised Officer 3

Name*:
Email*:
Phone*:
Signature*: / Name*:
Email*:
Phone*:
Signature*: / Name*:
Email*:
Phone*:
Signature*:

Goods to be exported

Dual Use* YesNo

/

Military *YesNo

Company Description

Parent Company Details(if applicable)

If your company is a subsidiary of another company, either in Ireland or abroad, please complete this section /

Agent Details (if applicable)

If your company uses an agent or representative to act it’s behalf for export control purposes, please compete this section
Name*:
Address Line 1*:
Address Line 2:
Address Line 3:
County* (if Ireland)
Post Code:
Country*:
Telephone Number*
Fax Number:
Website Address: / Name*:
Address Line 1*:
Address Line 2:
Address Line 3:
County* (if Ireland)
Post Code:
Country*:
Telephone Number*
Fax Number:
Website Address:

Agents Authorised Officer Contact Details

(We recommend that you nominate at lease 2 authorised officers. 3 is the maximum number that can be nominated)

Agent Authorised Officer 1*

/

Agent Authorised Officer 2

/

Agent Authorised Officer 3

Name*:
Email*:
Phone*:
Signature*: / Name*:
Email*:
Phone*:
Signature*: / Name*:
Email*:
Phone*:
Signature*:

I register the above exporter with the Licensing Unit of the Department of Jobs, EnterpriseInnovation for export control purposes. I declare that the particulars furnished above are correct. I hereby authorise the above named individuals to act on behalf of this company for export control purposes. I agree that any changes to the above information will be provided to the Licensing Unit by one of the individual’s named above.

Signed: ______

Printed Name: ______

Position: ______

(Must be one of the following: Managing Director, Financial Director/Controller; Company Secretary; Chief Executive Officer)

Email Address: ______

Telephone Number: ______

Date: ______

Please Note: Before submitting your licence application to the Licensing Unit please check that all the information you have provided is correct. If we request a change or additional information, we will return the application for you to make the necessary changes. We will only begin to process your application once we have received all the necessary information.

Revised December 2016 / Page 1 of 2