U.S. Export Control Information Request Form U.S. EXPORT CONTROL INFORMATION REQUEST CUSTOMER INFORMATIONCompany Name* Company Division* Customer Name* First Last Customer Address* Address Line 1 Address Line 2 City State / Province Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country TECHNICAL INFORMATIONContract/Purchase OrderFor additional rows, please click on the '+'. ProductWe 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 NumberCustomer Part NumberProduct DescriptionComponentSubsystem or SystemPlatform/End ProductITAR 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 CHAINBecause 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/ConsigneeNameAddressCityState/ProvincePostal CodeCountry Second Supply Chain Customer/ConsigneeNameAddressCityState/ProvincePostal CodeCountry Final End-User in Country of Final Destination*NameAddressCityState/ProvincePostal CodeCountryADDITIONAL INFORMATIONI 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* MM slash DD slash YYYY * I understand that checking this box constitutes a legal electronic signature certifying the answers are correct and complete to the best of my knowledge. CAPTCHA