End-Use/End-User Statement - Fredericks Company

Description

In accordance with The Fredericks Company and Televac^®’s commitment to compliance with the United States Government export trade regulations, we (the purchasing company) hereby provide the following information regarding the product(s) we are purchasing from The Fredericks Company and Televac^®.

Customer Purchase Order Number(Required)

For online orders, enter your Order Number. Online Order Numbers can be found in your confirmation email or in the My Account section of our website.

Economic Operators’ Registration and Identification (EORI) Number

Required for all European Union (EU) countries, Norway, and Switzerland.

End Use Information

Product End Use(Required)

Commerical or Civil

Industrial

Militaire

Ultimate End Use Application(Required)

Purchaser Information

Purchaser Company Name(Required)

Purchaser Company Website Address(Required)

Purchaser Complete Address(Required)

Purchaser Role(Required)

Will You Be Using a Foreign Intermediary?(Required)

Foreign Intermediary Information

Foreign Intermediary Company Name*

Add addendum of additional intermediaries if necessary.

Foreign Intermediary Website Address

Foreign Intermediary Complete Address

Foreign Intermediary Role

Upload Addendum (If Necessary)

Déposez vos fichiers ici ou

Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 5.

Ultimate End Use Information

Same As

Same As Purchaser

Ultimate End User Company Name(Required)

Ultimate End User Company Website Address(Required)

Ultimate End User Complete Address(Required)

Ultimate End User Role(Required)

Consent(Required)

We, the purchasing company listed below, certify that the item(s) being purchased from The Fredericks Company or Televac^® will not be re-exported or sold for export without the prior authorization of the U.S. Government or as otherwise authorized by U.S. law and regulations. Furthermore, we confirm that the item(s) will not be used for purposes associated with chemical, biological, or nuclear weapons or missiles capable of delivering such weapons nor will they be resold if we know or suspect that they are intended or likely to be used for such a purpose.

Je suis d'accord

Signature(Required)

Name of Responsible Official(Required)

Titre(obligatoire)

Date(Required)

Responsible Official Company Name(Required)

Courriel(obligatoire)

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