New Supplier Form


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Section I. Business Information

 

Company Information

 
 
 
 

Please print/scan the applicable document below; email to globalprocurement@iriworldwide.com;or fax to 312-474-2202

W-8-Form Foreign Countries

W-9 Form IRS

 
 
 
 
 
 
 
 
 
 
 

Contact's Information

 
 
 
 
 
 

Section II. Business Biography

Company Data

 
 
 
 
Geographical Service Area*



 
Company Insurance


 

Products and/or Services

 

Certification Information

 

 

 

 

 

 

 

 

 

 

 

 

Ownership and management information

 
Listed company, its subsidiary or controlled company:*



 
 
Details of beneficial owner(s) - individual(s)*

 
 
Are there any Politically Exposed Persons (PEPs) among your institution’s ownership structure?*
 
Are there any PEPs in the Executive Management?*
 

Exposure to sensitive sanctioned countries and selective programmes

To the best of your knowledge, is the company or are any of the company’s Connected Parties or Other Related Parties currently targeted by sanctions administered by the following bodies: UN, EU, UKHMT, HKMA, OFAC, or as part of local sanctions law?*
 
To the best of your knowledge, does the company have any current Business Activity involving individuals, entities or organizations which are currently targeted by sanctions administered by the following bodies: UN, EU, UKHMT, HKMA, OFAC, or as part of local sanctions law?*
 
Does the company, or any of the company’s Connected Parties or Other Related Parties to the best of your knowledge, have any current presence in the following countries?*
Cuba, Iran, North Korea, and Syria
The current listing can be found at https://www.bis.doc.gov/index.php/policy-guidance/country-guidance/sanctioned-destinations
 
Does the company, to the best of your knowledge, have any current Business Activity in the following countries?*
Balkans, Belarus, Burundi, Central African Republic, Democratic Republic of Congo, Iraq, Lebanon, Libya, Russia, Somalia, Ukraine, Venezuela, Yemen, and Zimbabwe.
A current listing of thoe sanctions can be found at https://home.treasury.gov/policy-issues/financial-sanctions/sanctions-programs-and-country-information
 
Does the company or any of the company’s Connected Parties or Other Related Parties to the best of your knowledge, have any current presence or current Business Activity in Crimea/Sevastopol regions?*
 
Does the company, to the best of your knowledge, have any current exposure to Russia:*
  1. in the energy, military or defence industry sectors?
  2. any deep-water, Arctic offshore or shale projects that have the potential to produce oil anywhere in the world?
 
Is the company 50% or more owned or controlled or any current Business Activity by the government of Venezuela?*
 

General AML Policies, Practices and Procedures

Do you have a legal and regulatory compliance program that includes a designated officer that is responsible for coordinating and overseeing the AML framework?*
 
Is the financial crime compliance program approved by your institution’s board or a senior committee?*
 
Has your institution developed written policies documenting the processes that you have in place to prevent, detect, and report suspicious transactions?*
 
In addition to inspections by the government supervisors/regulators, does your institution have an internal audit function or other independent third party that assesses AML and CTF policies and practices on a regular basis?*
 
Does your institution have record retention procedures that comply with applicable law?*
 
Does your institution have record retention procedures that comply with applicable law?*
 

False Representation of Business Statement

I hereby represent that the information provided is true and accurate.

 
 
 
 

Terms and Conditions

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Vendor Code of Conduct

Vendor Code of Conduct and Information Security Policy

 
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