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: |
| 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 |
I hereby confirm the completeness and correctness of the information provided herein.
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| Supplier Name |
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| Date/Location |
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| Signature |
Table 1
| ECCN | Percentage of the incorporated US-origin content into your product based on Fair Market Value |