End User Statement - Access-Electronics.com

Date:*

Date:

Purchase Order No.(s)*

The information requested below is required by the United States Export Laws and Regulations, In Lieu of this formal Statement, all of the required information may be included on your Purchase Order.

Ultimate Consignee:

Address Line 1:

Address Line 2:

Telephone Number:

Fax Number:

Foreign End User:

Address Line 1:

Address Line 2:

Telephone Number:

Fax Number:

Foreign Intermediate Consignee (Purchaser):

Address Line 1:

Address Line 2:

Telephone Number:

Fax Number:

U.S. Freight Forwarder:

Address Line 1:

Address Line 2:

Telephone Number:

Fax Number:

Specific Purpose of Product (i.e. flight, shipboard, test equip, etc.):**

Specific Program or Platform Name For Product:**

I certify that all the information submitted in accordance with the End-Use Statement is correct and complete. That it is fully and accurately discloses all facts pertinent to this transaction. (s). I further certify that the products purchased will not be used for proliferation of nuclear, missile, chemical or biological warfare. I acknowledge that the making of false statement or concealment if any material fact in connection with this statement may result in imprisonment or fine, or both and denial, in whole or in part, of participation in U.S. exports and re-exports.

Name of Company & Signer:*

Title of Signer:*

Date Signed:*

Date Signed:

End User Statement Agreement:

I agree to and acknowledge the terms above, and provided accurate information throughout.
I agree to and acknowledge the terms above with the exception of: (Please explain below)

If you selected the second option & have an exception with the agreement terms above, please explain further: