The following form must be completed and signed by a company officer in order to purchase a Bosch 25/30Hz Thermal Imaging CCTV Camera. This form is valid for both standard resolution (MIC612TF-) and high-resolution (MIC612HF-) models.
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Once the form is completed, printit on paper with your company’s letterhead, sign the form,and then send it to the Bosch Security Systems Order Desk via mail, fax, or other electronic means.
ON CUSTOMER LETTERHEAD
End-User Statement
We, (Company Name), understand that the Bosch 25/30HzThermal Imaging CCTV Camera contains components that are controlled for export by the United States Department of Commerce, Bureau of Industry and Security, and any sale or transfer of this system requires the prior approval of the US Government.
We certify that the Bosch 25/30Hz Thermal Imaging CCTV Camera and/or its components will be used for (Intended Camera Purpose) in (City/Country). We further certify that the use of the Cameras is strictly by a civil end user for civil end-use and will not be used or sold for use for any of the following activities:
A. Nuclear explosive activities, safeguarded and/or unsafeguarded nuclear activities including research, development, design, manufacture, construction, testing or maintenance of any nuclear explosive device or components or subsystems, nuclear reactor, critical facility, facility for the fabrication of nuclear fuel, facility for the conversion of nuclear material from one chemical form to another, facilities for the chemical processing of irradiated special nuclear or source material, facilities for the production of heavy water, facilities for the separation of isotopes of source and special nuclear material, or facilities for the fabrication of nuclear fuel containing plutonium.
B. Rocket Systems (including ballistic missile systems and space launch vehicles, sounding rockets, unmanned air vehicles including cruise missile systems, target drones and reconnaissance drones).
C. The design, development, production, stockpiling or use of chemical or biological weapons.
D. Civil End User/Use does NOT include any national armed services (army, navy, marine, air force, or coast guard), as well as the national guard and national police, government intelligence or reconnaissance organizations, or any person or entity whose actions or functions are intended to support "military end-uses" including but not limited to Intelligence, reconnaissance, or surveillance systems suitable for supporting military operations.
The following Bosch 25/30Hz Thermal Imaging CCTV Camera will be used:
Commercial Type Number / Quantity / Purchase Order numberWe understand and acknowledge that we are responsible for compliance to export regulations, including any returns for repair and/or other services.
Authorized Signature:
Print Name:
Position/Title:
Company Name:
Address:
Date:
rev. 2.0