A Jewell Instruments Company          603-622-0452        information@dghcorp.com

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Quoted transportation costs may vary and other import fees may apply for international orders. It is recommended that online orders for “next day” delivery be confirmed with our factory.

Click here if you plan to export your purchase.

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    END USE CERTIFICATE

    Due to recent changes to the US Federal Trade Regulations, we have revised this form to include additional information that is required to process any US exported items. Your assistance in supplying this information is mandatory with the new regulations.

    To determine if this order requires an export license, please complete this form and return it to us as quickly as possible. The completed form can be printed out and faxed to 603-669-5962 or saved and emailed as an attachment to your Jewell customer service rep. Please contact our Sales department at 800-227-5955 or 603-669-6400 with any questions.

    Please complete the ENTIRE form. Any missing or vague information will result in unnecessary delays.

    1. Is the person completing this form fluent in the English Language?     YesNo

    2. Exact description or model of Jewell Instruments’ product to be exported:

    3. Customer Purchase Order Number:      4. DGH Sales Order Number:



    5. Ultimate Consignee (The company or persons receiving the product from Jewell Instruments):



    Company Name:      Street Address
    City      State/Province      Postal Code:
    Country:    Telephone:     Website Address:



    6. Intermediate Consignee (Forwarding agent, broker, etc.):         Not Applicable


    Company Name:      Street Address City      State/Province     Postal Code:
    Country:    Telephone:     Website Address:



    6. End User Information (Final End User if not the Ultimate Consignee):         Check here if end user is the same as the Ultimate Consignee listed in Section 5


    Company Name:      Street Address
    City      State/Province     Postal Code:
    Country:    Telephone:     Website Address:

    8. Ultimate End User as stated above is: Direct ConsumerGovernment EntityResellerOther (identify)
    9. What is the MAIN INDUSTRY of the END USER?    

    10a. Please describe the EXACT END USE of the product: (ex. measure angle of tilt; or measure vibration level):    

    10b. Please describe the EXACT APPLICATION of the product: (ex. movement of subway car; or camera stability):    

    11. Please check the appropriate End Use or Application: MilitaryNon-military

    CONTROLLED DESTINATION CERTIFICATION

    By signing the END USE CERTIFICATE, I certify to the best of my knowledge and under penalty of United States law that this Jewell Instruments product will not be sold or transferred to any entity other than those listed within this document. I further certify that this Jewell Instruments product will not be sold to any individual or entity prohibited by the U.S. Department of Commerce, Bureau of Export Administration or the U.S. Department of State and that all parties will adhere to the directions provided in the Executive Order (EO) 13224, "Executive Order On Terrorist Financing - Blocking transaction with persons who commit, threaten to commit or support terrorism" effective 9/24/2001 and any subsequent changes made to it.
    (To view EO13224, please access the following website: )https://www.state.gov/executive-order-13224/

    I further certify that this Jewell Instruments product will not be sold or transferred to any entity in Cuba, Libya, North Korea, Rwanda, Angola, Iraq, Syria, Sudan, Iran, or any other prohibited country as designated by U.S. policy or law. I further certify that this Jewell Instruments product will not be use on any missile, chemical, nuclear, or biological weapon system of which the end destination is outside the United States of America.

    CONTROLLED DESTINATION CERTIFICATION - ELECTRONIC TRANSMISSIONS

    This END USE CERTIFICATE is being transmitted electronically and executed by electronic signature in lieu of a hard copy. The parties to this transaction agree that this electronic END USE CERTIFICATE shall have the same force and effect as if executed and sent in hard copy. The buyer certifies that those representations and certifications contained in the document are current and accurate to the best of their knowledge.

    CERTIFICATE SIGNATURE/AUTHORIZATION

    Name:      Company Name:
    Position:      Date:
    Signature:

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