EXPORT END USE(R) FORM
(D4-SG48)
Peter Gaines
Company Name: ____________________________________Sender Name: _________________________________
MARC OLANIE
[email protected]
ATTN:____________________________________________Sender
Email: _________________________________
+44 1252 837010
Initial Order #: _____________________________________Return Fax #: __________________________________
Thank you for submitting your request to us. We appreciate the opportunity to be of service to both you and your
company. Please provide us with the following information so that we may complete the processing of your order.
Company Name of End User:
(If customer completing this form is the manufacturer of the end product you may insert your name as end user)
Company Address of End User: ___________________________________________________________________
____________________________________________________________________________________________
Country of End User: ___________________________________________________________________________
Describe how the parts will be used by the End User (the End Use):_______________________________________
____________________________________________________________________________________________
This Export End User Form will be valid for future orders for the same parts ordered by you, pursuant to the
initial order identified above, for 6 months from the date below; and if this form is not dated below, then it
will be valid for 6 months from the date of receipt of this Export End User Form by Mini-Circuits Europe as
set forth in Mini-Circuits Europe’s records. This Export End User Form will be valid for such future orders
only if such additional orders are for the same end user, end use, and end country as specified above. If you
order the same parts for a different end user, end use, or end country, or if you order different parts, you
must submit a new Export End User Form. Nothing herein shall be construed to limit Mini-Circuits Europe
from requiring a new Export End User Form to be submitted by you before processing any order.
The undersigned hereby represents that the above information is accurate and that the part(s) stated in the
undersigned’s order will not be exported, re-exported or released (a) to any of the following countries or a national
thereof: Cuba, Iran, North Korea, Sudan, Syria or any country specified in Country Groups D:1 or E (as specified in
the then current Supplement No. 1 to Part 740 of the U.S. Export Administration Regulations), (b) to any country
specified in Schedule 4, Part 1 and Part 2 of the Export Control Order 2008 promulgated under the U.K. Export
Control Act of 2002, (c) to any entity or person specified in the then current Treasury Department Specially
Designated Nationals and Blocked Persons List available at the U.S. Department of Treasury website
(www.treasury.gov), (d) to any entity or person on the then current Unverified List available at the Bureau of
Industry and Security website (www.bis.doc.gov), (e) to any entity or person on the then current Denied Persons List
also available at the Bureau of Industry and Security website, (f) to any entity as specified in Entity List Supplement
No. 4 to Part 744 of the U.S. Export Administration Regulations, (g) to any entity or person on the then current U.K.
Strategic Export Control Lists made available at the Department for Business Innovation and Skills website
(www.bis.gov.uk), or (h) in any manner, to any person, entity or country, or for any use, except in compliance with,
and with all applicable licenses, license exceptions and approvals required under all applicable United States, U.K.,
European, and foreign export laws, rules, restrictions and regulations, including, without limitation, the U.S. Export
Administration Regulations, the Arms Export Control Act, the International Traffic In Arms Regulations, and the
C U S T O M P R O D U C T N E E D S . . . Let Our Experience Work for You.
D4-SG48 Rev.: B
M133639
(09/27/11) File: D4SG48.doc
This document and its contents are the property of Mini-Circuits.
Refer to: D3-SC09
Sheet 1 of 2
U.K. Export Control Act of 2002. Diversion therefrom contrary to U.S., U.K. or other European law or directive is
prohibited.
IF YOU KNOW OR SUSPECT THAT THE PARTS ON THIS ORDER WILL BE USED IN A WEAPONS OF
MASS DESTRUCTION (WMD) PROGRAM OR IN A WMD DELIVERY SYSTEM, OR IF YOU HAVE BEEN
INFORMED THAT THE DUAL-USE PARTS ON THIS ORDER (1) ARE OR MAY BE INTENDED FOR
INCORPORATION INTO MILITARY EQUIPMENT, OR FOR THE DEVELOPMENT, PRODUCTION, OR
MAINTENANCE OF SUCH EQUIPMENT, OR FOR THE USE IN A PLANT FOR PRODUCTION OF SUCH
EQUIPMENT IN AN EMBARGOED DESTINATION; OR (2) ARE INTENDED FOR USE AS PARTS OR
COMPONENTS OF ILLEGALLY OBTAINED (FROM THE U.K.) MILITARY GOODS IRRESPECTIVE OF
DESTINATION OR ARE AWARE OF SUCH INTENDED USE, THEN PRIOR AUTHORIZATION/EXPORT
LICENSE IS REQUIRED AND YOU ARE REQUIRED TO NOTIFY US WITH THE DETAILS IN ADVANCE.
This Export End User Form and the execution, interpretation, construction, and enforcement hereof are governed by
the laws of the United States of America and New York State.
(Signature)
(Date)
C U S T O M P R O D U C T N E E D S . . . Let Our Experience Work for You.
D4-SG48 Rev.: B
M133639
(09/27/11) File: D4SG48.doc
This document and its contents are the property of Mini-Circuits.
Refer to: D3-SC09
Sheet 2 of 2