End User Statement

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Headed paper -
END USER STATEMENT
SECTION 1 - PARTIES
1
2
a. Name of the Romanian licensee
b. Licensee's Reference
3
c. Name of Consignee
d. Consignee's Address
4
e. Name of End-User
f. End-User's Addresses
g. Is the end-user the armed forces or
h. Specific location where goods will be
5
internal security forces of the country?
used or based (if known) and if different
6
Please DELETE an option:
from f.
Yes / No
SECTION 2 - GOODS
7
c. Value and
a. Quantity of
b. Description of the goods
currency
Goods
SECTION 3 - END-USE OF THE GOODS
8
Please set out the specific purposes for which the goods are to be used by the end-user
9
SECTION 4 - END-USER STATEMENT
(to be completed by the person or body named in 1e. and 1f.)
We, the person or body named at 1e. and 1f., certify that we are the end-user of the
goods described in Section 2, which are to be supplied by the licensee named in 1a. We
further certify that we shall use the goods for the purposes described in Section 3; that
the goods will not be used for any purpose connected with chemical, biological or
nuclear weapons, or missile capable of delivering such weapons;that they will not re-
exported or otherwise re-sold or transferred if it is known or suspected that they are
intended or likely to be used for such purposes; that the goods will not be re-exported
or otherwise re-sold or transferred to a destination subject to UN, EU or OSCE
embargo where that act would be in breach of the terms of that embargo; and that the
goods, or any replica of them, will not be used in any nuclear explosive activity or
unsafe guarded nuclear fuel cycle.
Sign Here
________________ ____________ Date _______________ ___
(Signature of official of End User)
Print Name _____________________________
(Add Name of Signatory in Capitals)
Role
_____________________________
(Add Job Title of Signatory in Capitals)

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