[Seite 1]
Declaration on Export Control Classification
The following information is required in order to comply with export control regulations, if applicable.
| Supplier’s Information | |
|---|---|
| Name: | |
| Address: | |
| Email: | |
| Phone: | |
| Purchase Order No.: | |
| Supplier Part Number: | |
| Item Description: |
| Manufacturer’s Information (if different from Supplier) | |
|---|---|
| Name: | |
| Country of origin: | |
| Commodity Code ( HS Code): |
| Is the product subject to supplier’s national export control regulation? | ||||
|---|---|---|---|---|
| Dual Use Item | ☐ NO | ☐ YES | Control List Classification: | |
| Military Item | ☐ NO | ☐ YES | Control List Classification: |
| Is the product subject to US-Export Regulations? | ||||
|---|---|---|---|---|
| EAR | ☐ NO | ☐ YES | ECCN or EAR99 | |
| ITAR | ☐ NO | ☐ YES | USML List Category | |
| If the License Exception or CCAT available, please provide the No. |
| If your product has other than US country of origin, please provide the information referred to incorporated components subject to US-Export Regulations: | ||
|---|---|---|
| ECCN or EAR99 | ☐ NO | ☐ YES, than please fill in Table 1 |
If you have further deviating details to the other order items , please add the details here again by opening/closing the affected positions
[Seite 2]
Signatures/ Confirmation
Klicken oder tippen Sie hier, um Text einzugeben. Supplier Name
Klicken oder tippen Sie hier, um Text einzugeben. Date/Location Klicken oder tippen Sie hier, um Text einzugeben. Signature
Table 1 ECCN Percentage of the incorporated US-origin content into your product based on Fair Market Value