49 Rider Avenue, Patchogue, NY 11772
Tel: 631 289-0363 ● Fax: 631 289-0358
Web:
END-USER CERTIFICATE / Date(mm/dd/yyyy): Click or tap to enter a date.
THIS STATEMENT MUST BE ISSUED BY THE CONSIGNEE OR END USER
Dear Valued Customer,
Export of Narda-ATM products may be subject to the United States Government’s Export Administration Regulations (“EAR”) or International Traffic in Arms Regulations (“ITAR”). Please complete and return this certificate so we may process your purchase order [PO] or request for quotation [RFQ].
This form must be completed in English and in its entirety. There must be one separate form for each end use and/or program. Please list complete names (identify acronyms) and addresses of all parties involved (no PO Boxes).
RFQ or PO No.: / RFQ or PO Date(mm/dd/yyyy): Click or tap to enter a date.
Qty / Model number(s) / Description (attach additional sheet, if necessary):
Purchased Items (select appropriate box) :☐Sub-System ☐Component ☐Part ☐Accessory/Attachment
Purchaser Information: / End User Information:
Company: / Company:
Address: / Address:
City/Province: / City/Province:
Zip Code: / Country: / Zip Code: / Country:
Telephone: / Fax: / Telephone: / Fax:
Contact Name: / E-Mail: / Contact Name: / E-Mail:
Additional Information: / Additional Information:
Intermediate Consignee Information: / Ultimate Consignee Information:
Company: / Company:
Address: / Address:
City/Province: / City/Province:
Zip Code: / Country: / Zip Code: / Country:
Telephone: / Fax: / Telephone: / Fax:
Contact Name: / E-Mail: / Contact Name: / E-Mail:
Additional Information: / Additional Information:
Specific End Use application(select all appropriate boxes): ☐Commercial ☐Military ☐Military R&D ☐Spare/Replacement ☐Ship ☐Airborne
☐Ground-based ☐Space ☐Missile ☐Unmanned Aerial Vehicle (UAV) ☐Other: Click or tap here to enter text.
Describe the specific End-Use and Program(if available):
By signing here (Your Company Name) certifies that the items herewith will not be used for any purpose connected with chemical, biological, or nuclear weapons, or missiles capable of delivering such weapons, nor will they be resold if we know or suspect that they are intended or likely to be used for such purpose. The items will not be re-exported as such, without the prior written consent of the US Government.
Signature of Authorized Company Officer:
Name (Printed):
Title: / Date (mm/dd/yyyy): Click or tap to enter a date.
PLEASE TYPE or PRINT CLEARLY. RETURN BY Email:
STATEMENT OF ULTIMATE CONSIGNEE AND PURCHASER: We certify that all of the facts contained in this statement are true and correct to the best of our knowledge and we do not know of any additional facts, which are inconsistent with the above statement. We shall promptly send a supplemental statement to the U.S. Exporter, disclosing any change of facts or intentions set forth in this statement which occurs after the statement has been prepared and forwarded, except as specifically authorized by the U.S. Export Administration Regulations (15 CFR parts 730-774), or by prior written approval of the Bureau of Industry and Security, we will not re-export, resell, or otherwise dispose of any items approved on a license supported by this statement (1) to any country not approved for export as brought to our attention by means of a bill of lading, commercial invoice, or any other means, or(2) to any person if we know that it will result directly or indirectly, in disposition of the items contrary to the representations made in this statement or contrary to Export Administration
49 Rider Avenue
Patchogue, New York, 11772
Tel:(631) 289-0363 Fax:(631) 289-0358
Instructions for completing the End-User/End-Use Form
Item 1RFQ or PO No.: List all request for quotation and purchase order number pertaining to this certificate.
Item 2RFQ or PO Date: List all request for quotation and purchase order dates pertaining to this certificate.
Item 3Qty/Model number(s): List the products purchased from the U.S. Company (L-3 Narda-ATM).
Item 4Purchased Items: Identity the products purchased from the U.S. Company (L-3 Narda-ATM).
Item 5Purchaser: Identify the party purchasing the products from the U.S. Company (L-3 Narda-ATM).
Item 6Foreign End User: Enter the complete name and address of the foreign end user(s). The end user is the entity that will take final possession of the commodity, regardless of foreign purchaser(s) and foreign intermediate consignee(s). Note: Must show complete name and address, P.O. Boxes or imprecise addresses may result in delays in processing.
Item 7Foreign Intermediate Consignee: List all parties who will receive the goods for onward movement to the ultimate consignee/end user. If there is no foreign intermediate consignee, list “none”. There may be one or more foreign intermediate parties involved in the transaction (for ex.: freight forwarders, customs broker, agents or representatives). Note: Must show complete name and address, P.O. Boxes or imprecise addresses may result in delays in processing. Use additional sheet to list all parties involved, if necessary.
Item 8Foreign Ultimate Consignee: The foreign purchaser who will receive the shipment for storage, modification, or for incorporation into another end-item and for subsequent forwarding to the foreign end user. Note: Must show complete name and address, P.O. Boxes or imprecise addresses may result in delays in processing.
Note: An ultimate Consignee may also be the actual foreign end user if they are consuming the product.
Item 9Specific end use application: Please check appropriate boxes.
Item 10Specific Purpose and program for which the material is required: Provide the specific purpose of the requested export. Simply stating, “for use in production of military aircraft” or “for resale” is inadequate. A few examples of a specific detail are:
“For production of the AB/CDE-100 Ground-penetrating radar (GPR). The radar will be used probe the subsurfacevolcanic, icy and arid terrains by the NISA project JLL-12345 in the Jet Land Laboratory”; or “For test and evaluation for use on the TR amplifier, in support of NATO Contract N56789”
“Items will be integrated into a communication satellite earth station program: The unit is to be integrated by DEF Company in its earth station TACT123. The TACT123 is a Satellite communication earth station that to it is used within the German Interactive Program.
Item 11Certification for Statement of Ultimate Consignee and Purchaser: Company Name, officer name, signature and date of end user or duly authorized representative who can provide the required certifications.