U.S. Export Control Information Request Form

CUSTOMER INFORMATION

Company Name*

Company Division*

Customer Name*

First Last

Customer Address*

Address Line 1 Address Line 2 City State / Province Postal Code Country

TECHNICAL INFORMATION

Contract/Purchase Order

For additional rows, please click on the '+'.

Product

We ask that you provide specific information regarding each product that you are ordering from Positronic. Even though the subsystem/system or platform may be subject to the U.S. Department of State’s International Traffic in Arms Regulations (ITAR), the product itself may be subject to U.S. Department of Commerce’s Export Administration Regulations (EAR) if the component into which it is incorporated is subject to the EAR. In short, if we cannot properly classify the component and know what platform in which it is used, it is very difficult to classify the product we are manufacturing for you that is a part of the component and therefore to know what U.S. export control licensing requirements apply. Identify Component, Subsystem/System, and Platform/End Product into which Product will be incorporated. For additional rows, please click on the '+'.

Part Number	Customer Part Number	Product Description	Component	Subsystem or System	Platform/End Product	ITAR USML/EAR CCL Classification

EAR §§ 736.5 and 736.7 General Prohibitions on End-Uses and End-Users*

With respect to any of the products listed above that are classified under the Commerce Control List, please check any boxes below that apply regarding the ultimate end-use or end-user of the product. If none of the boxes apply to the products, please check none. In the additional field provided below, please explain the reason you checked any of the foregoing boxes relating to the EAR's General Prohibitions on End-Uses and End-Users.

None
Nuclear End-Uses (EAR § 744.2)
Maritime Nuclear Propulsion End-Uses (EAR § 744.5)
Chemical and Biological Weapons End-Uses (EAR § 744.4)
Rocket Systems (incl. ballistic missile systems, space launch vehicles, or sounding rockets) or Unmanned Air Vehicles (incl. cruise missiles systems, target drones, and reconnaissance drones) End-Uses (EAR § 744.3)
“Military End-Use” in the People’s Republic of China or a “Military End-Use” or “Military End-User” in Russia or Venezuela (EAR § 744.21)
Electronic Connectors Controlled by ECCNs 3A611.y.1 & 3A611.y.9 (EAR § 744.9)
Cameras controlled by ECCN's 6A003.b.3, 6A003.b.4.b. or 6A003.b.4.c. (EAR § 744.9)

Explanation

SUPPLY CHAIN

Because U.S. export and re-export control also require licensing for specific end-uses and end-users, please list below the names and addresses of the parties to the supply chain through which the product(s) will pass. For additional rows, please click on the '+'.

First Supply Chain Customer/Consignee

Name	Address	City	State/Province	Postal Code	Country

Second Supply Chain Customer/Consignee

Name	Address	City	State/Province	Postal Code	Country

Final End-User in Country of Final Destination*

Name	Address	City	State/Province	Postal Code	Country

ADDITIONAL INFORMATION

I hereby certify that I am authorized by my company to provide the foregoing information, that the information provided is accurate and complete, and that my company undertakes to inform you immediately of any subsequent change(s) thereto.

Company Name*

Name*

Title*

Signature*

Date*

I understand that checking this box constitutes a legal electronic signature certifying the answers are correct and complete to the best of my knowledge.

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