(PRINT ON YOUR COMPANY LETTERHEAD OR PROVIDE EQUIVALENT INFORMATION ON YOUR COMPANY’S FORM)

END USE STATEMENT

Purchaser information:

Name:

Street address 1:

Street address 2:

City:

State/Province:

Postal Code:

Country:

Nature of Purchaser’s business:

Part Information:

Quantity:

Unit of Measure:

Part Number:

Part Description:

Purchase Order or Contract Information:

Purchase Order Number:

Purchase Order Date:

Country of Ultimate Destination:

This Commodity is being financed under (check one):

Foreign Military Sale

Case number:

Foreign Military Financing

Case number:

Grant Aid Program

Case number:

Not Applicable

Ultimate End User: (Manufacturer of final end product)

Name:

Street address 1:

Street address 2:

City:

State/Province:

Postal Code:

Country:

Nature of Ultimate End User’s business:

Foreign Consignee (such as component or contract manufacturer):

(Same as ultimate end user)

Purpose/Role of Foreign Consignee:

Name:

Street address 1:

Street address 2:

City:

State/Province:

Postal Code:

Country:

(If more than one foreign consignee, please attach additional information)

Foreign Intermediate Consignee #1 (such as a distributor or freight forwarder):

None (check box if none)

Purpose/Role of Foreign Intermediate Consignee:

Name:

Street address 1:

Street address 2:

City:

State/Province:

Postal Code:

Country:

Foreign Intermediate Consignee #2 (such as a distributor or freight forwarder):

None (check box if none)

Purpose/Role of Foreign Intermediate Consignee:

Name:

Street address 1:

Street address 2:

City:

State/Province:

Postal Code:

Country:

(Please attach additional foreign intermediate consignee information if needed)

End Use is:

Defense (military)

Military Program:

Space:

Launch Provider:

Launch Site:

Country:

Launch Vehicle:

Other

Specific purpose for which the Tech Etch, Inc. parts will be used:

Application (specific purpose) of the parts:

Countries where the product will be used:

Specific end product the parts will be incorporated into:

U.S. Consignor and/or freight forwarder:

Name:

Street address 1:

Street address 2:

City:

State/Province:

Postal Code:

Is the End User the armed forces or internal security forces of its country?:

Yes	No

If it is known or believed by us that the goods will be re-exported or are not intended to be used within the specific country or by an individual or corporation not authorized to receive such goods, then we have a legal obligation to immediately inform you prior to shipment.

I [Enter Name of Responsible Customer Official] hereby certify that we will only export to the country and End User specified above.

___________________________________

Signature of Responsible Company Official

Type Full Name of Responsible Company Official

Title of Responsible Company Official