APPENDIX A1
THIRD PARTY DUE DILIGENCE QUESTIONNAIRE
I. Company Information2
Full legal name:
Address of principal place of business:
Place of incorporation:
Location of all other offices:
Main contact person:
(Name, title, phone, and email)
Website Address:
Number of employees:
Prior company name(s):
II. Ownership and Management
1. For privately-held companies, please provide the following ownership information:
Legal Name Country of Principal Place of Ownership Ultimate Parent
Organization or Business (if Percentage Entity (if
Nationality applicable) applicable)
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necessary necessary necessary rows as as necessary
necessary
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To be completed by the third party prior to entering into an agreement with any third party who will be acting on
behalf of Pico (e.g. distributors, joint venture partners, freight forwarders, customs brokers, external sales agents,
representatives, and consultants).
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If you are an individual and are being considered as a Pico third party intermediary in your individual capacity,
please provide responsive information to the questions in Part I (all), Part II (questions 5 and 6), Part III (all), Part
IV (all), Part (V) (all, but question 11) with respect to you as an individual.
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2. For publicly-held companies, please list all interim and ultimate parent companies, if any:
Legal Name Interim/Ultimate Country of Principal Place of Ultimate
Organization or Business (if applicable) Parent Entity
Nationality (if applicable)
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as necessary as necessary necessary necessary rows as
necessary
3. Please provide the following information for the company officers and members of the board
of directors:
Legal Name Title Nationality
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necessary
4. Are there any other persons or entities able to exercise control over the company through any
other arrangement or relationship other than those listed above? If so, please provide the
following information:
Legal Name Relationship to Country of Principal Place of Ultimate
Company Organization or Business (if applicable) Parent Entity
Nationality (if applicable)
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as necessary as necessary necessary necessary rows as
necessary
5. Are any of the company or the company’s affiliates’ owners, directors, principals, officers,
employees, representatives, or retained third parties a government official? If yes, please
provide the following:
Legal Name Company Title Govt. Official Title Govt. Agency and
Country
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necessary necessary necessary necessary
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6. Do any of the company or the company’s affiliates’ owners, directors, principals, officers,
employees, representatives, or retained third parties have any familial, personal, or
professional affiliations with any government official? If yes, please provide the following:
Legal Name Company Title Nature of Govt. Agency and
Relationship to Govt. Country
Official
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necessary necessary necessary necessary
III. Business Operations
1. Please describe the company’s core
business activities:
2. Please list all countries that the
company operates in:
3. Please attach copy of the company’s
most recent annual and quarterly
financial statements, audited (if
available) and non-audited.
4. Is the company regulated or supervised
by local regulatory authorities? If so,
are the shares of the company listed on
any exchange? If so, which exchange?
5. Please provide the name of the
company’s supervisory or regulatory
authority and, if available the
registration number.
IV. Use of Intermediaries3
Please provide the following information regarding any intermediaries that will be used by the company
in connection with providing services to Pico:
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Intermediaries is defined herein as any third party (company or individual) whom you might hire or use in any way
for purposes of conducting or carrying out business on behalf of Pico, including but not limited to, agents, sub-
agents, contractors, sub-contractors, consultants or any other third-party.
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Legal Name of Physical Email Address Phone Number Website
Intermediary Address
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necessary as necessary necessary necessary necessary
1. Please describe the services that each
intermediary listed above will provide.
2. Has the company conducted due
diligence on the intermediaries?
3. Does any government official, or a close
family member of a government official,
have any direct, indirect, or beneficial
interest in any of the intermediaries?
4. Do any of the intermediaries have any
other ties to any government officials?
V. Compliance
For the below questions, “company” includes the legal entity, as well as its owners, directors,
principals, officers, and employees.
1. Has the company been the subject of any
legal, regulatory, arbitral, or exchange
proceedings in the last 5 years?
If Yes – please describe the nature of the same
and what action has been taken to rectify?
2. Has the company ever been suspended
from doing business or convicted of,
charged with, or otherwise alleged to
have engaged in fraud, bribery,
misrepresentation, or any other criminal
act?
If Yes – please describe the nature of the same
and what action has been taken to rectify?
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3. Has the company ever been a party to a
proceeding in any country for violation
of applicable anti-bribery or anti-
corruption laws or regulations?
If Yes – please describe the nature of the same
and what action has been taken to rectify?
4. During the past 5 years, has the
company directly or indirectly given,
offered, or promised money or any other
thing of value to a government official?
If yes, please explain.
5. During the past 5 years, has the
company received a request for
payment, gift or kickback from any
government official?
If yes, please explain.
6. Has the company ever been a party to a
proceeding in any country for violation
of applicable human rights laws or
standards?
If Yes – please describe the nature of the same
and what action has been taken to rectify?
7. Is the company the subject of any
sanctions administered or enforced by
government authorities, including the
U.S. Department of the Treasury’s
Office of Foreign Assets Control
(“OFAC”), the U.S. Department of
State, the United Nations Security
Council, the European Union, Her
Majesty’s Treasury, or other relevant
government authority?
If yes, please explain.
8. Does the company have any business
dealings (including through investments
or other transactions, customers,
business partners, or other third parties)
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in Cuba, Iran, North Korea, Syria, or
Russia?
If yes, please explain.
9. Does the company have any business
dealings with any persons (natural or
legal) who are the subject of sanctions
administered or enforced by government
authorities, including OFAC, the U.S.
Department of State, the United Nations
Security Council, the European Union,
Her Majesty’s Treasury, or other
relevant government authority?
If yes, please explain.
10. Has the company ever been the subject
of a sanctions-related enforcement
action by OFAC, the U.S. Department of
State, a Member State of the European
Union, Her Majesty’s Treasury, or any
other relevant government authority
that is responsible for investigating
and/or administering sanctions and
export controls?
If yes, please explain.
11. Does the company have policies and
controls in place related to:
a. sanctions and export controls
laws
b. bribery and anti-corruption
c. prevention of money laundering
d. prohibition of human trafficking
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Name: ___________________________
Title: ______________________________
I have reviewed the information provided herein and certify that it is accurate and complete. I/the
Company will promptly notify Pico in the event of any change in the information provided.
Signature: ___________________________ Date: ______________
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