End-User Statement for Export - Brownells

End-User Statement for Export

END USER

Name: Address: City, country: Postal Code: Firm register number: Phone/Fax: Contact person(s):

Description of the main activity:

Certificate number (for official use)

EXPORTER

Name: Address: City, country:

Postal Code: Customs number:

Brownells Inc. 200 South Front Street Montezuma, IA

50171-9989

DESCRIPTION OF GOODS/TECHNOLOGIES

QUANTITY

UNIT PRICE

TOTAL VALUE

Grand Total: Supplementary information (Any other material facts which will be of value considering applications for license covered by this statement.)

End-Use Description of end-use (Including purpose and place):

Statement by the End User: We certify that all the facts contained in this statement are true and correct to the best of our knowledge and belief and we are not aware of any additional facts which are inconsistent with the above statement. We shall promptly send a supplemental statement to the exporter disclosing any changes of facts or intentions set forth in this statement which occurs after the statement has been prepared and forwarded. We will not re-export, resell of any commodities listed above, to any country not approved for export and to any person if there is reason to believe that it will result directly or indirectly, in disposition of the commodities contrary to the representation made in this statement

END USER (Signature in ink) ............................................................... (Seal)

Signature of official of End User

Date

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