End Use, End User, and Ultimate Destination Statement
Download Form: 3-EUS (End-User Statmnt) FORM
*Customer Name:
*Contact Person:
*Address:
(P.O. box only not acceptable!)
Telephone number:
Facsimile:
E-mail:
Website:
1. *Purchase Order Number: (Mandatory!)
2.
Transaction Reference Number:
(Optional!)
3. *Identify the end user, end use and the country of ultimate destination of these products: a) Identify the END-USER of these products (Full Company / Person Name & Address required!)
(b) *Specify the end user’s final application / END-USE for these products:
(c) *Specify where the end-user will use these products, i.e., the Ultimate Destination Country:
4. *Please indicate any intermediate users by name and country location (if relevant).
(a) Indicate the name and address of the intermediate consignee:
(b) Specify the nature and purpose of the intermediate users’ involvement.
5. *Name, title, and signature of the declarant:
Name:
Title: Date:
Signature: (**Blanket Period):
*MANDATORY Fields!
**Blanket period can be used for multiple orders featuring the same data as above!
Items exported under this PO are subject to the US-EAR Regulations for re-export, resale, or transfer to any foreign 3rd party. Such transaction must be reported to Persistent Systems in advance!
Thank you for your cooperation!
