Return a Signed Copy of the Completed Document To

Dear Customer,

Thank you for choosing to purchase a FLIR Systems product. We are confident you will be satisfied for years to come.

As a requirement for our sale to you, we are obligated by the U.S. Department of Commerce to collect certain information and/or documentation related to the end use of FLIR 9 Hz products. This document is designed to assist you in providing this data to us.

Return a signed copy of the completed document to

If this product will be used by a military end-user (defined below) or incorporated into a military commodity, please contact your FLIR representative for additional instructions.

Thank you,

FLIR Global Trade Compliance

9 Hz End Use/End User Statement

Section 1 – CONTRACT INFORMATION
Name and Address of Purchasing Party / Name and Address
Purchase Order/Contract Number / PO or Contract Number
Date of Order / Choose Date
Product Description and Quantity / Description and Quantity
Section 2 - END USER INFORMATION AND END USE OF THE PRODUCT
End User Name / End User Name
Full Address / End User Address
Military End User?
(national armed services, including army, navy, marine, air force, coast guard; national guard; national police; government intelligence or reconnaissance organizations; or any person or entity whose actions or functions are intended to support military end-uses) / ☐ Yes ☐ No
Incorporated into a Military Commodity? / ☐ Yes ☐ No
Military End Use?
(meaning incorporation into a military item described on the U.S. Munitions List or on the Wassenaar Arrangement Munitions List; or to commodities classified under any U.S. Commerce Control List “600” series ECCN, ECCN ending in “A018,” or ECCN “0A919;” or for the use, deployment or production of military commodities (regardless of country of origin) that are described on the U.S. Munitions List or the Wassenaar Arrangement Munitions List, or that are classified under any U.S. Commerce Control List “600” series ECCN, or ECCN ending in “A018,” or ECCN “0A919.”) / ☐ Yes ☐ No
Detailed description of the intended end use of the product (how will the equipment be used?) Provide comprehensive description of intended end-use. / Description
Integration/installation details- Advise if product is being integrated into a higher level item; or will be installed onto a platform such as a pole, rooftop, vessel, aircraft, or vehicle / Integration/Installation Details
Signature of person completing this form
I certify that the information provided herein is true, complete and accurate to the best of my knowledge. I also understand that these commodities are classified for export control purposes under Export Control Classification Number (ECCN) 6A993.a and that they may not be sold, retransferred or re-exported without first obtaining the appropriate authorization.
Name: / Name
Signature:
Title: / Title
Company Name: / Company Name
Date: / Date

4210053 Rev. A02/02/2017