Declaration of Usage - Access-Electronics.com

Customer P.O. #:*

Date of Purchase Order:*

Date of Purchase Order:

Please be aware that the following item(s) or part(s) are either dual usage or military. Consequently, the U.S. Bureau of Export Administration and the U.S. Department of State forbid companies to sell to certain denied countries, entities, or persons.

Part Number(s):*

Please have an officer of your company sign the acknowledgement below, and return a copy by email at orders@access-electronics.com, or fax at 732.446.2892. Also, please check the box below for the statement that applies to your situation.

We hereby certify that:

We are the end-user of the item(s) / part(s) cited above.
We are a reseller, and understand that it is our obligation to comply with any export restrictions that apply to this part.

We are aware of the resale restrictions to parties currently on the Bureau of Export Administration’s Denied Persons List(http://www.bis.doc.gov/DPL/Default.shtm) or Denied Entities List (http://www.bis.doc.gov/Entities/Default.htm), and International Traffic in Arms Regulation (ITAR) (http://www.pmdtc.org).

Company Name:*

Signature:*

Name & Title (printed):*

Date:*

Date: