The U.S. Department of State maintains and publishes on its travel.state.gov.website various lists of organizations that provide medical services that may be available to U.S. citizens overseas. The Department is prohibited from recommending any particular company and includes companies on its lists without any endorsement or recommendation. If you would like to be included on such a list, kindly provide the information requested below. The return of this questionnaire indicates your interest in having your company included on one of the Department’s lists of organizations providing medical services available to U.S. citizens overseas. The Department cannot guarantee that you will be included on one of the Department’s lists of providers. Inclusion of a company on a list is exclusively within the Department of State’s discretion; the Department may remove a company from a list at any time, and may decline to provide a reason. Generally, the lists are revised triennially, with interim addenda as needed, to ensure that listed companies are still operating and offering services, and that they wish to remain on the list. Thank you for your time and interest. PLEASE COMPLETE THE INFORMATION REQUESTED IN THE SPACE PROVIDED. IF YOU NEED ADDITIONAL SPACE, PLEASE ATTACH ADDITIONAL Department of CommerceUMENT/PAGES. Company Name: Address: Telephone: Email: Company Website: Point of Contact (Title and Contact Info): Services Provided: Location of Services Offered: Languages Spoken: Business Hours: After Hours Availability: Professional Association Membership; Professional Accreditation: Have there been any disciplinary actions against the company or an employee in performance of services for your company within the last five years by a professional accreditation association? If yes, provide details. Is the company currently in good standing with the appropriate accreditation organization? Please include proof of licensure and good professional standing when submitting this questionnaire.

The U.S. Department of State maintains and publishes on its travel.state.gov.website various lists of organizations that provide medical services that may be available to U.S. citizens overseas. The Department is prohibited from recommending any particular company and includes companies on its lists without any endorsement or recommendation. If you would like to be included on such a list, kindly provide the information requested below. The return of this questionnaire indicates your interest in having your company included on one of the Department’s lists of organizations providing medical services available to U.S. citizens overseas. The Department cannot guarantee that you will be included on one of the Department’s lists of providers. Inclusion of a company on a list is exclusively within the Department of State’s discretion; the Department may remove a company from a list at any time, and may decline to provide a reason. Generally, the lists are revised triennially, with interim addenda as needed, to ensure that listed companies are still operating and offering services, and that they wish to remain on the list. Thank you for your time and interest. PLEASE COMPLETE THE INFORMATION REQUESTED IN THE SPACE PROVIDED. IF YOU NEED ADDITIONAL SPACE, PLEASE ATTACH ADDITIONAL DOCUMENT/PAGES. Company Name: Address: Telephone: Email: Company Website: Point of Contact (Title and Contact Info): Services Provided: Location of Services Offered: Languages Spoken: Business Hours: After Hours Availability: Professional Association Membership; Professional Accreditation: Have there been any disciplinary actions against the company or an employee in performance of services for your company within the last five years by a professional accreditation association? If yes, provide details. Is the company currently in good standing with the appropriate accreditation organization? Please include proof of licensure and good professional standing when submitting this questionnaire.