End-Use / End-User Statement

The information supplied herewith should be used for U.S. license application purposes by the U.S. supplier:

1)	Purchaser:
2)	Address:

3)	Purchase order / Contract no.:
4)	PO / Contract date:
Copy of PO / Contract attached:	YES NO

5)	US Item: (reference)	6)	Quantity:	7)	Value: (USD)	8)	Classification: ITAR (USML) / EAR (CCL)	SME	MDE
Add lines if necessary.

9)	Supplier:
Name:
Address:
Must be completed also for Non-US-Suppliers, such as European equipment manufacturer, or non-US distributor, using US parts. This entity must be listed as the foreign consignee (12) on the license application, if this entity is the one receiving the parts from the US.

10)	US Manufacturer: If different from 9)
Name:
Address:

11)	End User / Country of ultimate destination:
Name:
Address:

12)	Foreign consignee:
Name:
Address:

13)	End Use:	Space Defense Others
Provide detailed program and application description:
Program:
How will this product be used in the above program? (Must provide detailed information regarding application, including a description of the countries where the product will be used.)

For space applications only:

14)	Launch provider:	15)	Launch site: (incl. country)	16)	Launch vehicle:
Add lines if necessary.

17)	Intermediate consignee:
Please note that all test facilities should be covered by this list of Intermediate Consignees.
Name and Address, Country	Purpose
17.1
17.2
17.3
17.4
17.5

18)	Separate End User Statement attached	YES NO
19)	DSP 83 attached	YES NO
20)	Accountability plan attached	YES NO
21)	Other documents attached (describe)	YES NO

22)	Nonproliferation statement: Commerce only
23)	Accountability statement / accountable (ITAR): Only if requested
24)	Specific statements: e.g. reporting obligations

25)	Signatures:
25.1	Name:
Dep./Title:
Date:
25.2	Name:
Dep./Title:	Export Control Administration
Date: