End Use Certificate to be Completed on Customer’s Company Letterhead
Date PO Number
Part Number Product Description Part Number Product Description
Purchaser Purchaser’s Customer Ultimate End-User
Postal Code, Country
Identify any other destinations of the goods (e.g., Customs Broker, Intermediate Consignee, etc.)
Business Type /
Postal Code, Country
Military Space / Satellite Commercial
Overall End Use of the Product(s):
Other, explain __________________________________________
Provide a detailed description of the higher-level system in
which product(s) will be used:
What is the function or purpose of this system?
Name the geographic location the product(s) / system be used
1. I (We) will not export or re-export U.S. products, software, technology or technical data (“U.S. Goods”) to Cuba, Iran, North Korea, Sudan, Syria or to
any restricted / embargoed country as may be designated from time to time by the U.S. Government unless otherwise authorized by the U.S.
2. I (We) will not sell, transfer, export or re-export any U.S. products for use in activities that involve the development, production, use or stockpiling of
nuclear, chemical, biological weapons or missiles, nor use these products in any facilities that are engaged in activities related to such weapons or
their delivery systems (e.g., ballistic missile systems, space launch vehicles, etc.)
3. I (We) acknowledge that U.S. law prohibits the sale, transfer, export, or re-export to or other participation in any export transaction involving U.S.
products with individuals or companies listed in the U.S. Department of Commerce’s Denied Persons List, Entity List or Unverified List; the U.S.
Department of Treasury’s Specially Designated Nationals and Blocked Persons Lists; or the U.S. Department of State’s Debarred Persons List.
4. I (We) will abide by all applicable U.S. export control laws and regulations for any products purchased from Teledyne and will obtain any licenses or
other approvals required by the U.S. Government prior to export or re-export of U.S. Goods.
5. In the event of a routed export transaction, Teledyne Storm Products is authorized to act as our authorized agent for export control, U.S. Customs
and Border Protection, and U.S. Census Bureau purposes to transmit such export information electronically that may be required by law or
regulation in connection with the exportation or transportation of any goods on our behalf.
Printed Name: Date:
Email: Tel. No.:
QF 2004 Rev F End Use Certificate DCRN # 1202023 Page 1 of 1