End User Certificate - Excel by zqx15399

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									                                   GOVERNMENT OF NEW ZEALAND
                                 End-User Certificate ‑ Dual Use Goods
Name of Consignor:

Name & street address
of Intermediate
Consignee

Name and street
address of End User:

Nature of Business:

Country of Final
Destination

                                               Item Description:
                                                                                           Part            Serial
Quantity                                   Description
                                                                                         Number(s)        Number(s)




                                         Intended End Use of Equipment




                        Certification by Intermediate Consignee/Intermediate End-User:
We certify that the equipment detailed above will be delivered to the nominated end-user only. Except with the
express prior written authorisation of the Government of New Zealand we will not re-export, re-sell, or otherwise
dispose of the equipment or any part of the equipment to any person other than the nominated end-user.
                           Signed:
                                                                                Date:
                        Name (Print):
                                                                                Seal:
                        Designation:


                   Department/Organisation




                                                                                              Continued on page 2: (over)
                                               Certification by End-User:
We certify that we are the end-user of the equipment detailed above. We certify that the equipment will not be used
in any activities related to the development or production of nuclear, chemical, or biological weapons, or in the
development of missile systems. Except with the express prior written authorisationof the Government of New
Zealand we will not re-export, re-sell, or otherwise dispose of the equipment or any part of the equipment.

                           Signed:
                                                                               Date:
                        Name (Print):
                                                                               Seal:
                         Designation:


                  Department/Organisation




I/We certify that the main activity of the company (end-user):



is:

as indicated on page one of this form.
                           Signed:
                                                                               Date:
                        Name (Print):


                         Designation:


                  Department/Organisation




                           Witness:



                       Witness Name:



                    Witness Designation



                  Department/Organisation

								
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