END-USER CERTIFICATE - PDF by ypy11747

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									                                                   SECURESEARCH, INC.
                                                            SCHEDULE “C”

                                                    END-USER CERTIFICATE
         (REQUIRED BY THE GOVERNMENT OF CANADA, DEPARTMENT OF FOREIGN AFFAIRS AND
           INTERNATIONAL TRADE, EXPORT CONTROLS DIVISION, OTTAWA, ONTARIO, CANADA)

When completed signed and sworn, this is a legal document required for supervision and control of international
trade in regulated products. Violation of government regulations may result in severe penalties and sanctions
being imposed in breach of national and international laws! Two copies of this document are to be returned to
SECURESEARCH, INC. or to our authorized sales representative by registered mall, before any goods can be
shipped. In certain cases, based on the information in this certificate, shipment may require issuance of a federal
export certificate or approval by the U.S. Department of Commerce.

1.   Name of Canadian exporter (Securesearch, Inc. or) :        Securesearch, Inc.
2.   Name of Importer:
Address :
Telephone number including country code and area code:
Fax number of Importer:                                                    e-mail address :______
3. (U.S.A. purchasers ONLY) MANDATORY I.R.S. Employer Tax ID no.(EIN) if importer is a company or agency:
Social Security Number if importer is an individual:
4. If importer is purchasing for sale to an authorized third party, provide the name, address, phone number, fax number of the third party :

(in the U.S.A. please provide the third party Federal Employer ID no. or Social Security Number):
5.   If goods are to be exported to a THIRD country, provide name and address of exporter:
Name & address of third country IMPORTER, if applicable:
6. END-USER IDENTIFICATION
Name of company or government agency/dept. designated as the end-user (final purchaser) of these goods :


Division:                                 Phone number:                               Phone ext. no. if applicable:
Fax number:                               e-mail address:                             _______________________________
Full street address of end user (Not a post office box no.) :
P.O. Box no.:                     City :                                 Country:                                Postal Code :
7. Brief description of goods purchased:
8. End use purpose for which goods are being purchased :
Purchase order no.:
9. Affirmation: "I certify that the Securesearch, Inc. products described above are only for use in (country name):
and will not be exported to any other country. We are the end-user".



            AUTHORIZED SIGNATURE                                 (PRINT OR TYPE YOUR NAME)                               TITLE

Witness name:                                                    Witness Signature:                                   Date:

                                                  Affix official stamp or seal of witness
                                                                  tak ing sworn oath here:
Following your completion of this          Mail/courier to:
Schedule please go to                             SECURESEARCH, INC.
www.securesearchinc.com/send.htm                  3500 PHARMACY AVENUE, UNIT 4
for instructions on how to send this              SCARBOROUGH, ONTARIO M1W 2T6
form to us. Thank you.                            CANADA
                                                  e-mail: info@securesearchinc.com
End of Schedule "C"                                PHONE: (416) 492-5349
(Rev. 10-11/2007)                                  FAX: (416) 492-3656

								
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