F-004-A END USER CERTIFICATE

End User Certificate

Export of these commodities is subject to either the United States Government’s Export Administration Regulations (“EAR”) or International Traffic in Arms Regulations (“ITAR”), and to regulations enforced by the U.S. Treasury Department’s Office of Foreign Assets Control (“OFAC”). Please complete and return this certification so we may complete the review of your purchase order or request for quotation.

P.O. Number

P.O. Date

Part Number(s) / Description / Quantity (attach additional sheet, if necessary):

Additional Part #s Info

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PURCHASER INFORMATION

Purchaser's Company Name

Purchaser's Website

Purchaser's Street Address

Purchaser's City

Purchaser's Postal / Zip code

Purchaser's Region/State/Province

INTERMEDIATE PARTY(IES) INFORMATION

If none, state "None." Attach an additional sheet, if necessary.

Intermediate Party's Company Name

Intermediate Party's Website

Intermediate Party's Street Address

Intermediate Party's City

Intermediate Party's Region/State/Province

Intermediate Party's Postal / Zip code

Additional Intermediate Party(ies) Info.

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END-USER INFORMATION

End-User's Company Name

End-User's Website

End-User's Street Address

End-User's City

End-User's Region/State/Province

End-User's Postal / Zip code

SPECIFIC END-USE

Please provide a complete and detailed statement of the end-use application of the product(s) listed above. Attach an additional sheet, if necessary.

To be installed in

operated by

Select one

Military End-Use

Civil End-Use

SIGNATURE OF AUTHORIZED REPRESENTATIVE

I (WE) AGREE that by signing below, your company certifies that the items herewith will not be used for any purpose connected with chemical, biological, or nuclear weapons, or missiles capable of delivering such weapons, nor will they be resold if we know or suspect that they are intended or likely to be used for such purpose. The items will not be re-exported as such without the prior written consent of the US Government. I (WE) FURTHER AGREE and understand that my electronic signature is the legally binding equivalent of my handwritten signature. I further agree that I submit my electronic signature below with full knowledge and consent to be legally bound to this agreement.

Name of Authorized Representative

Authorized Representative's Email

Title of Authorized Representative

Authorized Representative's Company

Authorized Representative's Signature

Date

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