8355 Hessinger Drive
Erie, Pennsylvania 16509 USA
Phone: 814.860.5700
Fax: 814.860.5811


...

Parker Autoclave Engineers - END USER AGREEMENT

We, the 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)

Company Name:
Address:
City/Town:
State/Province/Territory:
Zip: Country:
Telephone:
Fax:
Company Website Address (URL):**
(Required)
Email:**
(Required)
Signature:**
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** By entering your name above you hereby acknowledge and agree that you have read and understand the United States of America Export Laws.
Title of Signor
Date:

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)
:

Company Name:
Address:
City/Town:
State/Province/Territory:
Zip: Country:
Telephone:
Fax:
Company Website Address (URL):
Email:
 
Signature:
Title of Signor
Date:
Relationship to End-User

Company Name:
Address:
City/Town:
State/Province/Territory:
Zip: Country:
Telephone:
Fax:
Company Website Address (URL):
Email:
Signature:
Title of Signor
Date:
Relationship to End-User

Company Name:
Address:
City/Town:
State/Province/Territory:
Zip: Country:
Telephone:
Fax:
Company Website Address (URL):
Email:
Signature:
Title of Signor
Date:
Relationship to End-User

Inside Sales Representative: Please enter your Parker Autoclave Engineers Inside Sales Representative below
Name:
   

Note: If an export license is required, an original End-Use Certificate/Statement or legally certified copy must be issued.

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Revised: 10/24/2012