of the product(s) hereafter specified in Purchase Order #
or otherwise noted, do certify the specific application, purpose and end-use (Example: Oranges, for the process of making juice to sell to the general public) for the aforementioned item(s) to be:
We also state the general nature of our business (Example: off-shore well drilling) as:
Further, we acknowledge we are duly informed and hereby assure the item(s), herein disclosed, will not be exported, imported or re-exported for any purpose or activity in violation of United States of America export law.
(read United States of America Export Law)
Company Information: (Please fill out all applicable fields)
Other Parties: (Please fill out all applicable fields)
Please list all other parties to this transaction if ultimate consignee is other than end-user
(Example: Exporter, intermediate consignee, purchaser, distributor, 3rd party):
Note: If an export license is required, an original End-Use Certificate/Statement or legally certified copy must be issued.