Compliance rules for preventing bribery and corruption

Section 1: About you

Company/Individual Information

Company/Individual Name*:

Address* Line 1:

Address Line 2:

City/State:

Zip Code:

Country:

Telephone Number (with country code)*:

Website URL:

Company Structure

CorporationPartnershipOther

If other, please specify:

If corporation, place of incorporation:

Principle place of business*:

Other countries/territories of business:

Section 2: Owners of interests greater than 5%

Owner 1 Name:

Percentage of Ownership:

Owner 2 Name:

Percentage of Ownership:

Owner 3 Name:

Percentage of Ownership:

Section 3: Directors, Officers, Partners and/or Principals

Name:

Title:

Name:

Title:

Name:

Title:

Section 4: Primary Contacts

(If there are multiple contacts, please include key business contacts and the key contact for correspondence related to preventing bribery efforts)

A

Contact Name*:

Job Title*:

Telephone Number (with country code)*:

Email*:

B

Contact Name:

Job Title:

Telephone Number (with country code):

Email:

Section 5: Primary Bank

Primary Bank Name*:

Primary Bank Address Line 1:

Primary Bank Address Line 2:

City/State:

Zip Code:

Country:

Contact Name*:

Contact Title*:

Contact Telephone Number (with country code)*:

Section 6: Government employees or officials

During the past five years, have any of your owners, directors, officers, partners, principals or primary contacts (jointly "representatives") been government employees or officials, officials of a political party, candidates for public office or officials of a public international organization (collectively referred to as "government official")?*

YesNo

If "Yes", please identify the name and title of the relevant representative(s), the government position(s) s/he held; and the dates of government service.:

Section 7: Family or personal ties to government officials

Applying the definitions set out in the previous question, are any of your representatives closely connected through family or personal ties to a government official?*

YesNo

If "Yes", please identify the name and title of the relevant representative(s), and the name and title of the government employee(s) or official(s) to whom your representative is connected; and the nature of the relationships.:

Section 8: Publisher connections

To your knowledge, are any of your representatives closely connected through family or personal ties to customers, suppliers, distributors or employees of any Publishers whom you are representing?*

YesNo

If "Yes", please identify the name and title of the relevant representative(s), and the name and title of the government employee(s) or official(s) to whom your representative is connected; and the nature of the relationships.:

Section 9: Convictions or investigations

Have any of your representatives ever been convicted of or investigated, sanctioned or professionally suspended for bribery, fraud, corruption or money laundering; or been the subject of any government investigation in relation to the possible breach of any other laws?*

YesNo

If "Yes", please identify the name and title of the relevant representative(s), and explaining the investigation or conviction, including the date, offence, court and penalty.*:

Section 10: Written policy

Do you or the business entity for which you work have a written policy prohibiting bribery and/or corruption?*

YesNo

Section 11: Anti-Slavery Programme

Do you currently have a program in place that ensures that human trafficking and modern slavery do not exist in your operations and supply chain?*

YesNo

Please review the United Nations Anti Slavery Factsheet; https://una.org.uk/anti-slavery-day-factsheet

Section 12: Prepayments

Do you accept pre-payment from your customers for future subscription years (taking payment for subscriptions more than 8 months in advance of the start of the subscription period)?*

YesNo

If "yes", do you hold this money separately in an escrow account so it cannot be utilised until the payment is due to the publisher?

YesNo

Section 13: Training

Do you or the business entity for which you work train employees on preventing bribery and/or corruption?*

YesNo

Section 14: Contractual Relationship

Do you have an existing contractual relationship with any Publisher whom you are representing?*

YesNo

Section 15: Memberships

Are you a member of any professional governing bodies or Associations?*

YesNo

If "Yes", please name those professional governing bodies/Associations:

Do those professional governing bodies/Associations have standard guidelines and or statement of best practice?*

YesNo

If "Yes", do you confirm that you adhere to such Guidelines or Standards of Best Practice?*

YesNo

Section 16: Drop shipping or consolidation agents

Do you utilize the services of drop shipping or consolidation agents?*

YesNo

If "Yes", please provide contact details for any such drop shipping or consolidation agent utilized by you or your company:

A

Drop Shipping/Consolidation Agent Name:

Address Line 1:

Address Line 2:

City/State:

Zip Code:

Country:

Contact Name:

Contact Title:

Contact Email:

Description of Business Relationship:

Dates Worked Together:

Section 17: References

Identify at least two commercial references which indicate your good standing in the business community:

A

Commercial Reference Company Name*:

Address Line 1*:

Address Line 2:

City/State:

Zip Code:

Country:

Contact Name*:

Contact Telephone Number (with country code):

Contact Email*:

Description of Business Relationship*:

Dates Worked Together:

From:

To:

B

Commercial Reference Company Name*:

Address Line 1*:

Address Line 2:

City/State:

Zip Code:

Country:

Contact Name*:

Contact Telephone Number (with country code):

Contact Email*:

Description of Business Relationship*:

Dates Worked Together:

From:

To:

Section 18: Compliance

Do you agree to comply with the UK Bribery Act, the US Foreign Corrupt Practices Act, and local bribery laws, and with other anti-corruption laws and regulations that will be relevant to your business operations?*

YesNo

If No, please explain your reasoning:

Section 19:

Do you warrant and undertake to Publishers that your company and/or your agents and/or employees have never and shall not PAY any prohibited payments, directly or indirectly, to any private individual, company, organization or any official of any government or government agent or body, in connection with the performance of the services provided by you, in your own capacity or on Publishers behalf? A prohibited payment is a payment that is, or can reasonably be considered to be, contrary to the anti-corruption/anti-bribery laws of the UK, the USA or any other jurisdiction that you operate in?*

YesNo

Do you warrant and undertake to Publishers that your company and/or your agents and/or employees have never and shall not RECEIVE any prohibited payments, directly or indirectly, from any private individual, company, organization or any official of any government or government agent or body, in connection with the performance of the services provided by you, in your own capacity or on Publishers behalf? A prohibited payment is a payment that is, or can reasonably be considered to be, contrary to the anti-corruption/anti-bribery laws of the UK, the USA or any other jurisdiction that you operate in?*

YesNo

Section 20:

Do you warrant and undertake to Publishers that in connection with any business transactions involving Publishers;
- Your company has and shall apply effective disclosure controls and procedures
- Your company has and shall maintain proper and accurate books, records and accounts
- Your company has and shall maintain an internal accounting controls system to ensure the proper authorization, recording and reporting of all transactions and to provide reasonable assurances that violations of anti-corruption/anti-bribery laws of the applicable jurisdictions shall be prevented, detected and deterred.*:

YesNo

If No, please explain your reasoning:

Section 21: Signature

Please enter the name of the person who completed this form*:

Please enter the job title of the person who completed this form*:

I represent and warrant that the information I have given on this form is full and true and correct, to the best of my knowledge and belief, and that I have taken [all] reasonable steps required to form my knowledge and belief. I further acknowledge that I understand that I may be asked provide documented verification of various items on request. And further, I represent and warrant that I have answered fully and truthfully all questions regarding criminal convictions/records. I hereby authorize PSI to conduct a criminal background history investigation. I hereby expressly request, and give permission to, former and existing contracting partners and any persons who may have pertinent information concerning this verification to furnish such information to PSI. I agree to hold such persons harmless, and I do hereby release them from any and all liability for damage of any nature whatsoever for furnishing such information*:

Agree

I confirm that I have watched the training video made available to me by PSI Ltd:

Agree

Please enter an answer in digits: