AIG Vendor/Consultant Certification Program Application Please understand that all information requested in this application will be kept CONFIDENTIAL. AIG respects your privacy, and does not intend to compromise your trust and goodwill. DEFINITIONS USED IN THIS APPLICATION Vendor/Business Entity: This is your Company. It may be an incorporated company, or an individual doing business as (d.b.a.) a company (i.e., John Smith, d.b.a. Smith Plumbing of Peoria). Applicant: The person signing this application (an owner, officer, principal partner, etc) who is authorized to engage in this application process. Principal: Any individual holding 5% or greater interest in the Vendor/Business Entity, and who would typically hold a title of owner, general partner, limited partner, officer, or director. Employee/Consultant Subcontractor: Employees, Consultants and Subcontractors are those individuals who do not own significant (5% or more) interest in the Business Entity, and represent the Vendor/Business Entity at AIG. Important Notice If your company is publicly traded on a U.S. or foreign exchange, you are required to have those employees, consultants and/or sub-contractors who work with AIG (remotely or at an AIG facility) complete sections C-2 (Principal-EmployeeConsultant-subcontractor application AND C-3 (The Fair Credit Reporting Act Consumer Disclosure and General Authorization) If your company is privately held, you and your employees, consultants and/or subcontractors, who work with AIG (remotely or at an AIG facility) are required to complete ALL forms contained in this package. INSTRUCTIONS FOR THE APPLICANT It is the responsibility of the Applicant to complete the Vendor/Business Entity packet, and further to ensure that each Principal and any or all employees/consultants/subcontractors complete his/her packet. In accordance with the note above, All sections in this application need to be completed accurately and legibly, and the FCRA forms must be dated and signed. Additional Principal/Employee/Consultant/Subcontractor packets can be downloaded from www.aigscreen.com. Be sure to distribute complete packets, including the cover sheet that contains specific instructions for filling out the packet. After all of the packets are returned to you, and you have verified their completeness, mail the packets to: American International Group Inc. ATTN: Security Services Representative – CARCO Group, Inc. 70 Pine Street Corporate Security, First Floor New York, NY 10270 FAX: 212-742-8543 If you experience problems filling out this application, please do not hesitate to call CARCO at (800) 773-6506. The Customer Service Department can also be reached by e-mail at: aigscreen@carcogroup.com. NOTE: After the certification process is completed, you will be contacted regarding your status as an AIG Vendor/Consultant. If approved for certification by AIG, the Vendor/Business Entity’s status as an AIG Vendor/Consultant is subject to the terms and conditions of the applicable agreement between AIG and the Vendor/Business Entity. A-1 APPLICANT WORKSHEET This worksheet has been prepared to assist the Applicant in identifying those Principals, Employees, Consultants and Subcontractors whose information needs to be collected to begin the process of qualifying the Vendor/Business Entity as a Certified AIG Vendor/Consultant. This worksheet will also assist us in maintaining your file’s integrity, so be sure to return it with the Certification Program Application. Business Entity Name Please note: All principals who owns 5% or greater interest in the vendor/business entity must complete forms C-2 and C-3 in order for Vendor/Business Entity to be certified. NAME SELECT ONE Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor Principal Employee Consultant Subcontractor A-2 AIG Certification Program Application VENDOR/BUSINESS ENTITY INSTRUCTIONS All sections in this application need to be completed accurately and legibly. It is understood that you may not be able to answer everything asked of you, but please make a sincere effort to furnish the information requested. Incomplete information will result in our contacting you to request this information again. This packet has space for two business addresses (current and two prior). Should this packet prove to have less space than needed for the requested information, please make extra photocopies of the necessary form(s). NOTE: You are strongly encouraged to make a copy of all application materials for your records. B-1 INFORMATION ON VENDOR/BUSINESS ENTITY Vendor/Business Entity Name Fictitious Business Name (d.b.a.) Date Company Formed Current Address City County State Country Zip Phone # Fax # E-Mail present Dates at this address from to Parent Business Entity Name Federal Tax ID # of the Vendor/Business Entity SIC Code/Type of Business *AIG Manager Name Phone # *AIG Manager E-Mail @ AIG.com *AIG Company/Branch/Department Code: _______________/_______________/_______________ # of employees/consultants/subcontractors who represent vendor/business entity at AIG * Required PRIOR to start of background check. Prior Address Information – Please record all other addresses for the past seven (7) years, listed from most to least current. The following is a Mailing Address Company Address City State Zip Dates at this address Physical Address County Country from to month/year The following is a Mailing Address Company Address City State Zip Dates at this address month/year Physical Address County Country from to month/year B-2 month/year AIG Certification Program Application PRINCIPAL – EMPLOYEE – CONSULTANT SUBCONTRACTOR YOU ARE A PRINCIPAL if you hold 5% or greater interest in the Vendor/Business Entity. Typically, you would have a title of Owner, General Partner, Limited Partner, Officer, or Director. YOU ARE AN EMPLOYEE, CONSULTANT OR A SUBCONTRACTOR if (a) You own less than 5% in the Vendor/Business Entity, and (b) You represent the Vendor/Business Entity at AIG. If you do not fall within one of the above categories, it is not necessary for you to fill out this application packet. INSTRUCTIONS All sections in this application need to be completed accurately and legibly. It is understood that you may not be able to answer everything asked of you, but please make a sincere effort to furnish the information requested. This packet has space for four home addresses (current and three prior). Should this packet prove to have less space than needed for the requested information, please make extra copies of the necessary form(s). It is critically important that you also sign and date the FCRA form (page C-3). Work cannot begin on your application without our receipt of this signed and dated form. When you have finished completing this packet, return it to your manager, the owner/s, or the person who gave this application to you. NOTE: You are strongly encouraged to make a copy of this application packet for your records. C-1 INFORMATION ON PRINCIPAL/EMPLOYEE/CONSULTANT/SUBCONTRACTOR I am a Principal/Owner Employee Consultant Subcontractor Legal Name Last First Middle Alias or Maiden Names Date of Birth Social Sec. # Month/day/year Gender Male Female Drivers License # State of Drivers License Current Address City County State Country Zip from Dates at this address to present *Your Business Entity’s Name *Contact Name/Email Address *Contact Phone # Ownership Interest* % *AIG Company/Branch/Department Code: *Principal ONLY / / *AIG Manager Phone # *AIG Manager Name *AIG Manager E-Mail *AIG Business Group * Required before background check will be started. Prior Address Information – Please record all other addresses for the past seven (7) years, listed from most to least current. The following is a Mailing Address Address Physical Address City County State Country Zip Dates at this address from to month/year month/year Physical Address Address City County State Country Zip Dates at this address from to month/year month/year Physical Address Address City County State Country Zip Dates at this address from to C-2 Principal/Employee/Consultant/Subcontractor Information THE FAIR CREDIT REPORTING ACT (FCRA) CONSUMER DISCLOSURE AND GENERAL AUTHORIZATION (To be signed by Principal and all Employees working with AIG) In connection with the Business Entity’s application for vendor certification by American International Group Companies (AIG) to provide service to AIG, a Consumer Report, as this term is defined in the federal Fair Credit Reporting Act as amended (FCRA), 15 U.S.C. 1681 et seq., will be obtained by AIG from CARCO Group Inc., a consumer reporting agency. CARCO may not give out information about you to AIG without your written consent below. The Consumer Report may include a verification of your identity, a criminal history record check, financial, license, and a driving history check. By signing this form, you are authorizing AIG to procure a Consumer Report for the intended purpose only and no other. I hereby authorize AIG to obtain a Consumer Report on me contingent upon the limitations stated above. This authorization does not include the release of any medical information. This authorization is valid only for the purpose set forth herein. Printed Name _________________________________________________________________ Signature ___________________________________________________________________ Today’s Date _________________ Date of Birth ____________________ [NOTE: This form is valid for three (3) months only] Social Security # ______________________________ Driver’s License # __________________________________________ State _____________ AIG Contact Name & Email Address _______________________________________________ A photocopy or electronically generated copy of this form may be treated as original. C-3 AIG VENDOR CERTIFICATION PROGRAM INDIA CRIMINAL RECORD VERIFICATION RELEASE FORM INSTRUCTIONS All sections in this application need to be completed accurately and legibly. Subject must complete this form for each address in India in which the subject resided during the past 7 years. Please do not complete this form for US addresses. A separate form must be completed for each individual address. Make extra copies of the form as necessary. Period of Residence must include actual dates subject resided at address indicated. It is critically important that you also sign and date the form. Work cannot begin on your application without our receipt of this signed and dated form. When you have finished completing this packet, return it to your manager, the owner/s, or the person who gave this application to you. C-4 MAILING ADDRESS POST OFFICE BOX 1600 SMITHTOWN, NEW YORK 11787 Tel: 631.862.9300 Fax: 631.862.7471 Subject: INDIA CRIMINAL RECORD VERIFICATION We would be grateful if you could confirm from your records, whether out employee, whose details are given below, has had any criminal case booked against him during the period as indicated: Name: _________________________________ Father’s/Husband’s Name: _________________________________ Residential Address: _________________________________ _________________________________ Period of Residence: _________________________________ Thank you for your cooperation. CARCO Group, Inc. I hereby authorize all persons, courts, and law enforcement agencies to release such information without restriction or qualification. I authorize CARCO and any of their designees or agents to obtain a Consumer Report on me contingent upon the limitations stated above. I am willing that a Photostat or electronic duplication of this authorization be considered as effective and valid as the original. This authorization does not include the release of any medical information. This authorization is valid only for the purpose set forth herein. Printed Name: Signature: Today’s Date: Date of Birth: (NOTE: This form is valid for three (3) months only). C-5