End Consignee Statement / End Use Certification

NOT TO BE FILLED OUT BY THE END USER.

MUST BE FILLED OUT BY THE CUSTOMER PURCHASING DIRECTLY FROM SYMMETRY ELECTRONICS.

Dear Sir/Madam:

This is to certify that

will not use, transfer, export, and re-export, resell or otherwise dispose of any items purchased from Symmetry Electronics to any destination, end-user or for any end-use prohibited by the laws of the United States or any other applicable law where such law does not conflict with the laws of the United States; unless such use, transfer, re-export, resale or disposition is specifically authorized by a government agency with export authority over the items purchased or ordered by us from Symmetry Electronics

Ownership interest in the company is not held by a person(s) listed on the Office of Foreign Asset Controls (OFAC) Specially Designed Nationals List (SDN) or by Executive Order. Any subsequent designation of owners or employees will be reported to Symmetry Electronics.

End Use of Product(s)

Commercial or Personal End-Use

Commercial Personal Use

Military End-Use

Yes (Please identify below) No

Are you a distributor/trader/broker or are the items purchased for resale?

Yes No

Please provide the SHIPPING address for this order

Please explain application or purpose for items purchased

END USER INFORMATION
Country(s) of export/ re-export (list ALL countries you/your company ships to)

Countries you export and ship to

If none, please indicate "none".

Your Order's Shipping address and country

Are you shipping directly to a freight forwarder?

Yes No

Your web address

Distributor/trader/broker/resale Information

Full Name

Job Title

Phone Number

Full BILLING address for this order

Do you have a pending order?

Yes No

If we are unable to fulfill the above certifications, or if any of the above details given shall change at any time, we will advise Symmetry Electronics of the change in writing before placing any further orders.

* A new certification is required if the customer's name changes, or if the end user changes per order placed. Each certification expires 1 year after submission.

for this End Use Certificate, warrant the truthfulness of the information provided in this application.

Please type your First and Last Name

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree that all the above information is accurate and true.

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End Consignee Statement / End Use Certification

End Use of Product(s)

END USER INFORMATION Country(s) of export/ re-export (list ALL countries you/your company ships to)

Distributor/trader/broker/resale Information

END USER INFORMATION
Country(s) of export/ re-export (list ALL countries you/your company ships to)