FLIR Systems



Dear Customer,Thank you for choosing to purchase a FLIR Systems (“FLIR”) product. We are confident you will be satisfied for years to come.In order to ensure compliance with trade restrictions to which FLIR and our products are subject, as a requirement for our sale to you we must collect certain specific information and/or documentation related to the transaction, the intended end-user and the intended end-use of the product(s). This document is designed to assist you in providing this data to us. It will also allow us to determine what, if any, type of export authorization or export license may be required. We ask that you complete this document thoroughly and return a signed copy to us. For your information and assistance:Company Names: Please provide the full legal name (including trading name) of the end-user / consignee / purchasing party / bank(s) and any additional third parties involved in the transaction. Third parties include any freight forwarders, import brokers, resellers, integrators, service support providers, or translation services providers, as applicable. Please define any acronyms used in these descriptions. Addresses: Please provide the complete registered addresses for all parties. PO Box Numbers are not acceptable. When a street or road name is not available please provide a description of the physical location; for example, provide a GPS location or physical description of how to locate the facility to a visitor.Additional information: When the FLIR product is being integrated or incorporated into another item (e.g., equipment, aircraft, vessel, vehicle, etc.) please provide a detailed description of the end-product or the associated equipment. Please also provide a product brochure or data sheet if available.Definitions: For the purposes of this document:Military End-User includes but is not limited to the national armed services (army, navy, marine, air force, or coast guard), as well as the national guard and national police, government intelligence or reconnaissance organizations, or any person or entity whose actions or functions are intended to support military end-uses. With respect to Russia, this includes but is not limited to parties listed in Annex IV of Council Regulation (EU) No 833/2014 (as amended). Military End-Use means: incorporation into military items; for the use, development, production, or maintenance of military items, or for the use of production, test or analytical equipment and components therefor; use of any unfinished products in a plant for the production of military items; or for deployment in certain aircraft or aero gas turbine engines or related parts and components. [This includes specifically: incorporation into a military item described on the UK Strategic Export Control Lists or on the U.S. Munitions List (“USML”) in the U.S. International Traffic in Arms Regulations (22 C.F.R. Part 121); incorporation into a military item described on the Wassenaar Arrangement Munitions List (as set out on the Wassenaar Arrangement Web site at ); incorporation into items on the Commerce Control List in the U.S. Export Administration Regulations (15 C.F.R. Part 730 et seq.) (“EAR”) classified under Export Control Classification Numbers (“ECCNs”) ending in “A018” or under “600 series” ECCNs; for the “use,” “development,” or “production” of military items described on the USML or the Wassenaar Arrangement Munitions List, or items classified under ECCNs ending in “A018” or under “600 series” ECCNs on the Commerce Control List; or deployment of items classified under ECCN 9A991 as set forth in Supplement No. 2 to Part 744 of the EAR.]Use includes operation, installation (including on-site installation), maintenance (checking), repair, overhaul and/or refurbishing.Development is related to all stages prior to serial production, such as: design, design research, design analyses, design concepts, assembly and testing of prototypes, pilot production schemes, design data, process of transforming design data into a product, configuration design, integration design, layouts.Production means all production stages, such as: product engineering, manufacture, integration, assembly (mounting), inspection, testing, quality assurance.Please contact your FLIR representative if you have any questions.Thank you.Global Trade Compliance GroupELR Number:ELR NumberCER Number:CER NumberFLIR TRANSACTION INFORMATION SHEET (FLIRTIS)RUSSIA TRANSACTIONS ONLYSection 1 – CONTRACT INFORMATIONFLIR Department and Point of ContactFLIR Dept and POCName and Address of Purchasing PartyName and AddressContact person within the purchasing company responsible for assisting with the export license procedureName: NameEmail address: EmailTelephone number: TelephonePurchase Order/Contract NumberPO/Contract NumberDate of OrderDateProduct Description and QuantityProduct Description and QuantityRole in the Transaction (if more than just the purchasing entity)Role in TransactionDetails of ownership and control: direct and indirect beneficial owners (shareholder(s)) of Purchasing Party and respective shareholdings) and names of directors and officers of Purchasing Party[If multiple shareholders, please provide copy of ownership structure]Details of Ownership and ControlWebsiteWebsiteCommission(s) to be Paid (amount and to whom being paid)CommissionPayment Terms ?Payment in advance?Letter of credit (Please specify the name and address of the issuing, confirming and any intermediary banks for the Letter of Credit in Section No. 5 below)?Net 30 days?Other Section 2 - END-USER INFORMATION AND END-USE OF THE PRODUCTEnd-User NameEnd-User NameFull AddressAddressContact PersonName: NameEmail address: EmailTelephone number: TelephoneMilitary End-User? (Refer to definition on first page)?Yes ?NoMilitary End-Use? (Refer to definition on first page)?Yes ?NoWill the product be used in Russia for exploration for, or production of, oil or gas in any of the following?Deepwater projects (i.e., greater than 500 foot depth)?Yes ?NoOffshore projects in the Arctic Ocean or above the Arctic Circle?Yes ?NoShale projects?Yes ?NoDetails of ownership and control: direct and indirect beneficial owners (shareholder(s)) of End-User and respective shareholdings) and names of directors and officers of End-User [If multiple shareholders, please provide copy of ownership structure]Details of Ownership and ControlWebsite AddressWebsiteNature of Business (what does the company manufacture, or what service is being provided?) Provide as much information as possible.Nature of BusinessDetailed description of the intended end-use of the product (how will the equipment be used?) Provide comprehensive description of intended end-use.End-Use DescriptionIntegration/installation details- 1.) Provide specification and/or brochure of end-product; 2.) Provide details if product is being installed onto a platform such as a pole, rooftop, vessel, aircraft, or vehicle.Integration/Installation DetailsProvide serial number and previous authorization (license number) if this is a re-export/transfer request.Serial Number and AuthorizationSection 3 – CONSIGNEE (If different from the Purchasing Party/End-User, provide the contact details of the company that will receive the product)Consignee NameNameFull AddressAddressContact PersonName: NameEmail address: EmailTelephone number: TelephoneDetails of ownership and control: direct and indirect beneficial owners (shareholder(s)) of Consignee and respective shareholdings) and names of directors and officers of Consignee[If multiple shareholders, please provide copy of ownership structure]Details of Ownership and ControlWebsite AddressWebsiteNature of Business (what does the company manufacture, or what service is being provided?) Provide as much information as possible.Nature of BusinessDetailed description of the intended end-use of the product (how will the equipment be used?) Provide comprehensive description of intended end use.End-Use DescriptionIntegration/installation details- 1.) Provide specification and/or brochure of end-product; 2.) Provide details if product is being installed onto a platform such as a pole, rooftop, vessel, aircraft, or vehicleIntegration/Installation DetailsSection 4 – ADDITIONAL PARTIESParty No. 1Company Name NameFull AddressAddressContact PersonName: NameEmail address: EmailTelephone number: TelephoneWebsite Address WebsiteRole of Party in TransactionRole in TransactionNature of Business (what does the company manufacture, or what service is being provided?) Provide as much information as possible.Nature of BusinessDetailed description of the intended end use of the product (how will the equipment be used?) Provide comprehensive description of intended end-use.End-Use DescriptionIntegration/installation details- 1.) Provide specification and/or brochure of end-product; 2.) Provide details if product is being installed onto a platform such as a pole, rooftop, vessel, aircraft, or vehicleIntegration/Installation DetailsParty No. 2Company NameNameFull AddressAddressContact PersonName: NameEmail address: EmailTelephone number: TelephoneWebsite AddressWebsiteRole of Party in TransactionRole in TransactionNature of Business (what does the company manufacture, or what service is being provided?) Provide as much information as possible.Nature of BusinessDetailed description of the intended end-use of the product (how will the equipment be used?) Provide comprehensive description of intended end-use.End-Use DescriptionIntegration/installation details- 1.) Provide specification and/or brochure of end-product; 2.) Provide details if product is being installed onto a platform such as a pole, rooftop, vessel, aircraft, or vehicleIntegration/Installation DetailsParty No. 3Company Name NameFull AddressAddressContact PersonName: NameEmail address: EmailTelephone number: TelephoneWebsite AddressWebsiteRole of Party in TransactionRole in TransactionNature of Business (what does the company manufacture, or what service is being provided?) Provide as much information as possible.Nature of BusinessDetailed description of the intended end-use of the product (how will the equipment be used?) Provide comprehensive description of intended end-use.End-Use DescriptionIntegration/installation details- 1.) Provide specification and/or brochure of end-product; 2.) Provide details if product is being installed onto a platform such as a pole, rooftop, vessel, aircraft, or vehicleIntegration/Installation DetailsSection 5 – BANKSProvide names and full addresses of any banks or payment intermediaries that will be involved in the transactionBank Name and AddressDescribe role(s) of any banks or payment intermediaries (e.g. remitting bank, issuing/confirming/advising bank for letter of credit, etc.)Role of BankWhat currency will be used for payment?Currency UsedSection 6 – CERTIFICATION AND SIGNATURE I certify that the information provided herein is true, complete and accurate to the best of my knowledge, and that:The products acquired from FLIR will not be directly or indirectly exported, reexported, sold, rented, leased, transferred, diverted, or otherwise used or disposed of in violation of, or in any manner that would cause FLIR to be in breach of, any applicable sanctions and export controls, including those maintained by the United States, European Union and its Member States, Canada, or other countries.The products will not be used in the design, development, production or use of nuclear, chemical or biological weapons or missiles. The products are not destined or intended for (i) any military end-customer, (ii) any military end-use, or (iii) for the design, development, production or use of chemical, biological, or nuclear weapons or their precursors, or of missile technology or unmanned aerial vehicles, or for terrorist activities. The products will not be supplied for use, directly or indirectly, in the exploration for or production of oil or gas in deepwater (greater than 500 feet), Arctic offshore, or shale projects in Russia.Customer is not, and no parties involved in the transaction are, identified on any restricted party lists maintained by the United States, European Union and its Member States, or Canada. Such restricted party lists include but are not limited to the Specially Designated Nationals and Blocked Persons List (“SDN List”) and Sectoral Sanctions Identifications List (“SSI List”) maintained by the U.S. Office of Foreign Assets Control; the Entity List, Unverified List, and Denied Persons List maintained by the U.S. Bureau of Industry and Security; the EU/UK Designated Parties List, the EU/UK Investment Ban Targets List, and entities listed in Annex IV of Council Regulation (EU) No 833/2014 (as amended); and the Anti-terrorism Financing List maintained by the Canada Office of the Superintendent of Financial Institutions as well as the Canadian Special Economic Measures (Russia) Regulations, Freezing Assets of Corrupt Foreign Officials (Ukraine) Regulations, and Special Economic Measures (Ukraine) Regulations (collectively, “Canada Restricted Party Lists”). Customer is not, and to the best of Customer’s knowledge no parties involved in the transaction are, owned or controlled by one or more parties identified on the SDN List, SSI List, EU/UK Designated Parties List, or Canada Restricted Party Lists. The products are not intended for, will not be supplied to, and will not be part of any transaction involving the provision of goods, services or technology to Crimea, any person ordinarily resident in Crimea, or any entity in Crimea [and will not be sold, diverted, transferred or exported/reexported to any other sanctioned destination (currently: Cuba, Iran, North Korea, the Republic of Sudan, or Syria)].Name:NameSignature:Title:TitleCompany Name:CompanyDate:Date ................
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