End Use Statement Form By Ultimate Consignee And Purchaser

End Use Statement Form By Ultimate Consignee And Purchaser - Telectron

END USE STATEMENT BY ULTIMATE CONSIGNEE AND

PURCHASER

1. ULTIMATE CONSIGNEE

ADDRESS

TELEPHONE

FAX

WEBSITE

2. DISPOSITION OR USE OF ITEMS BY ULTIMATE CONSIGNEE NAMED IN BLOCK 1

We certify that the items:

A. __ Will be used by us in the form in which received in the country named in Block 1 and will not be reexported or incorporated into a different

end product.

B. __ Will be resold by us in the form in which received in the country named in Block 1 for use or consumption therein.

The specific end-use by my customer will be ___________________________________________________________________________________

C. __ Will be reexported by use in the form in which received to ________________________________________________________________________

D. __ Other (describe fully) _______________________________________________________________________________________________________

3 NATURE OF BUSINESS OF ULTIMATE CONSIGNEE NAMED IN BLOCK 1

The nature of our usual business is _______________________________________________________________________________________________

STATEMENT OF ULTIMATE CONSIGNEE AND PURCHASER

We certify that all of the facts contained in this statement are true and correct to the best of our knowledge and we do not know of any additional

facts which are inconsistent with the above statement. We shall promptly send a supplemental statement disclosing any change of facts or

Intentions set forth in this statement which occurs after the statement has been forwarded. We will not reexport, resell, or otherwise dispose of

any goods supported by this statement (1) to any country not approved for export by the United States or (2) to any person if we know that will

result directly or indirectly, in disposition of the items contrary to the representations made in this statement or contrary to the US Export

Administration Regulations.

4. SIGNATURE OF OFFICIAL ULTIMATE CONSIGNEE

5. NAME OF PURCHASER

NAME OF SIGNATORY

SIGNATURE OF PURCHASER

TITLE OF SIGNATORY

NAME OF PURCHASING OFFICIAL

DATE

STAMP

TITLE OF PURCHASING OFFICIAL

NOTE : IN CASE SIGNATURE / STAMP OF END USER IS NOT POSSIBLE DOCUMENTARY EVIDENCE OF END USER TO BE PROVIDED E,G,

UNPRICED COPY OF PO FROM END USER TO PURCHASER OR PROJECT DOCUMENTATION CONFIRMING THE PROJECT DETAILS / END USER

TO BE PROVIDED.

TELECTRON REF # MZ-KS/CC-001

End Use Statement Form By Ultimate Consignee And Purchaser - Telectron