Export 1 (Export of Dual - Use Goods) - DBEI



* Please note that all fields marked with an asterisk are mandatory, if these are not completed your application will be returned.

Guidelines: For assistance in completing this form, please consult our guidelines; you can download these from djei.ie or contact exportcontrol@djei.ie for further information.

Please note: The box numbers correspond to the box numbers on the export licence form

| |EUROPEAN COMMUNITY |EXPORT OF DUAL-USE ITEMS/TECHNOLOGY (REG. (EC) NO 1969/2016) |

| |Exporter and Agent Details |

|A |1* Name and Address of Exporter |7 Name and Address of Agent/Representative |

|P |Exporters must be registered with the Licensing Unit prior to completing |(if different to exporter) Fields marked with an asterisk are mandatory|

|P |this application form |if an Agent/Representative name is entered |

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|I | | |

|C | | |

|A | | |

|T | | |

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|N | | |

| |Name*: |Name*: |

| |Address1*: |Address1*: |

| |Address2: |Address2: |

| |Address 3: |Address 3: |

| |County*: |County: |

| |Post Code: |Post Code: |

| |Tel No*.: |Country*: |

| |Fax No.: |Tel No*.: |

| | |Fax No.: |

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| |Movement of the Goods |

| |8 Country of origin (if applicable) If there is more than one country of |9 Country of consignment (if applicable) If there is more than one |

| |origin, please attach Multiple Countries Form – Export 1b Form |country of consignment, please attach Multiple Countries Form – Export |

| | |1b Form |

| |11* Member State of current or future location of the |12* Member State of intended entry into the customs export |

| |goods |procedure |

| |13* Countries of final destination Please list the countries in alphabetical order. |

| |Does the box below contain your full list of countries? Yes ❏ No ❏ If No, please attach an additional sheet. |

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| |Details of Goods to be exported |

| |(if exporting more than one type of good, please attach Additional Goods Form – Export 1c Form) |

| |14* Description of the goods |15* Commodity code |16* Control list No. |

| | |17* Currency and Value |18 Quantity of the goods (if |

| | | |applicable) |

| | |Equivalent Value in Euro* | |

| |End Use Information |

| |19* End-use |20 Contract date (if applicable) |

| | |21* Customs export procedure |

| |General Information |

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| |22 Additional information |

| |Have you previously received a global licence*? |Yes No |

| |If yes, please enter most recent licence number: |

| |Please confirm the total number of sheets contained in this application*: _______ |

| |Additional Country List attached*? Yes No If yes, please confirm how many: _______ |

| |23* Are you aware that the goods in question are intended, in their entirety or in part, for use in connection with the |YES | |

| |development, production, handling and operation, maintenance, storage, detection, identification |NO | |

| |or dissemination of chemical, biological or nuclear weapons or the development , production, maintenance or storage of | | |

| |missiles capable of delivering such weapons? | | |

| |Are you aware that the goods in question are intended, in their entirety or in part, for a military end-use if the purchasing |YES | |

| |country or country of destination is subject to an arms embargo decided by a common position or joint action adopted by the |NO | |

| |Council or a decision of the OSCE or an arms embargo imposed by a binding resolution of the Security Council of the United | | |

| |Nations? | | |

| |Are you aware that the goods in question are intended, in their entirety or in part, for use as parts or components of |YES | |

| |military goods listed in the national military list that have been exported from the territory of that Member State without |NO | |

| |authorisation or in violation of an authorisation prescribed by national legislation of that Member State? | | |

| |I apply for an export licence in respect of the goods described above (and overleaf) and I declare that the particulars furnished by me are |

| |correct. I confirm that an application for the goods described above (and overleaf) has not been submitted to the licensing authority of another |

| |EU Member State. |

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| |Signature* _____________________________________________________ Date*____________________________ |

| |(Signatory must be registered with the Licensing Unit as an authorised signatory) |

| |PLEASE NOTE: Export Licences are posted to exporters (or agents if applicable). If you would like to make alternative arrangements, please contact|

| |the Licensing Unit. |

Please Note: Before submitting your licence application to the Licensing Unit please check that all the information you have provided is correct. If we request a change or additional information, we will return the application for you to make the necessary changes. We will only begin to process your application once we have received all the necessary information.

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