Via Gargano 1 – 20139 Milano
Italy
Tel: +39 02 4548 5255 - info@crazybell.com
PROSPECTIVE LICENSEE INFORMATION FORM
I.
INTRODUCTION
This form must be completed as a condition to Crazy Bell (CB) approving any proposal
submitted by a prospective licensee. In completing this form, and for purposes of submitting
a licensing proposal, each prospective licensee should be aware of the following:
1. The acceptance or review by CB of a proposal or this form imposes absolutely no
obligation on CB to accept any proposal from the prospective licensee or grant a
license. The acceptance of a proposal and the grant of a license are in the sole discretion
of CB and the Licensor.
2. This form will be used by CB to evaluate whether and under what circumstances CB
will grant a license to a prospective licensee.
3. All fees and costs incurred by a prospective licensee, whether for artwork or product
development, attorneys' fees, or the like are the sole responsibility of a prospective
licensee.
4. No legally binding contract exists until a prospective licensee has received from CB a
fully executed contract. All oral or written statements made prior to the due execution of
a formal contract as to the terms of a proposed license or whether a license is to be
issued by Signature are merely expressions of intention, not legally binding. CB
reserves the right to withdraw from any oral or written commitments made up until the
time when both parties have received the formal contract signed by both parties.
5. In the event the information provided in this form is discovered to be false, misleading,
or incomplete, any license that might be granted by CB will be subject to immediate
termination, without the return of any amounts paid or the abatement of amounts due to
pursuant to such license.
II.
GENERAL INFORMATION
Company Name:
Address of Principal Place of Business:
Mailing Address (if different from above):
Telephone
Fax
Website
Legal Form of Company (corporation, proprietorship, partnership, etc.)
Place of Organization
Year Established
Names of Principal Owners or Stockholders
(If your company is a proprietorship or partnership, please provide the names, addresses,
phone and fax numbers of the owners/partners on a separate sheet)
Principal Management:
President:
Vice President(s):
Chief Financial Officer
Accounts Payable Manager
Primary Contact Direct Telephone #
No. of employees in company (or in the relevant division)
III.
FINANCIAL INFORMATION
1. Company Tax I.D., VAT or Registration
Number (if applicable):
2. What were the gross annual sales for your entire company?
2013 ________________________
2012 ____________________________
2011 ________________________
2010 ____________________________
3. Is there outstanding any litigation, arbitration, claim, governmental or other proceeding or
investigation pending or threatened (or any basis therefor) against your company or any
of its representatives or agents? Yes
No
If yes, please attach a separate sheet providing all details.
4. Has the company, its principal owners/stockholders, or its principal officers ever been
through bankruptcy or receivership? Yes ________ No ________
If yes, please attach a separate sheet providing all details.
5. Are there any outstanding judgments or liens against your company? If so, attach a
separate sheet providing all details. Yes ________ No _________
6. Have any claims been filed against the company for trademark, copyright, or patent
infringements or for product liability? Yes _______ No _________
If so, please attach a separate sheet providing all details including disposition.
IV.
PRODUCT INFORMATION
1. Description and pricing of product(s) for which your company is seeking a license:
Product Description
(by product type, process of manufacture, materials used and size)
1.
2.
3.
4.
5.
6.
Wholesale
Price
Retail
Price
(per Unit)
(per Unit)
2. Estimate of annual wholesale U.S. dollar volume of the product(s) your company wishes
to sell under the license being sought (by product, if applicable).
Product 1
Product 2
Product 3
Product 4
Product 5
Product 6
________
________
________
________
________
________
2015
________
________
________
________
________
________
2016
________
________
________
________
________
________
2014
3. Does your company currently sell the product(s) in question? Yes ______ No ______
4. Please, name any licenses your company currently holds for the manufacture and
distribution of these products:
__________________________________________________________________________
__________________________________________________________________________
5. Private label brand names of products sold by your company:
V.
SALES & DISTRIBUTION
2. Types of Distribution and Percentage of Sales in each (mark percentages in blanks.
Example: Department Stores 25% ):
Upscale Department Stores
Upscale Boutique Stores
Department Stores
Mid-Tier Department Stores
Mass Market Retailers
Music Specialty Chains
Toy Specialty Chains
Music Specialty Independents
Toy Specialty Independents
Bed & Bath/Home
Grocery/Supermarket
Fashion Specialty Chains
Drugstore Chains
Fashion Specialty Independents
Drugstore Independents
Convenience Stores
Deep Discount Stores
Warehouse Clubs
Catalogues/Direct Marketing
Airport Shops
Other____ % (describe)
3. Current Geographic Areas of Distribution (please specify):
To facilitate in the processes between the licensee and licensor, please provide a contact for the following
categories:
Company/Licensee
Name
Licensing
Name
Title
Email
Phone
Fax
Title
Email
Phone
Fax
Title
Email
Phone
Fax
Title
Email
Phone
Fax
Product Development
Name
Royalty Reporting/Accounting
Name
Legal/Business Affairs
Name
The undersigned hereby authorizes CB and its authorized representatives to verify all information
contained in this form and attest that information presented on or with this form is to the best of the
undersigned's knowledge, true and correct.
Signed:
Full Name of Company
By:
Signature
Title
Date: