Customer End-User Certificate

To continue processing your order, this form must be completed, signed and returned to our Export Department. Please complete and email to export@mouser.com or Fax to +1(817) 459-5168. Please note that incomplete or illegible information can delay your order.

Company or Individual Information
Name or Company Name
KASSEN, DAVID	Federal ID or DUNS (please specify)
	
Address
HABERLOHER-DORFSTR. 2A	City
LANGWEDEL	
State/Providence/County
	Postal Code
27299	Country
GERMANY	Company Website Address (if any)
	
1. Have you or has your company ever been convicted of violating U.S. Export Laws and Regulation?  If Yes, provide details below.	o Yes o No	
Details:	
2. Are you or is your company currently listed on the Denied Person List, Unverified List or Entity List of the Bureau of Industry and Security, Department of Commerce?   http://www.bis.doc.gov/index.php/the-denied-persons-list	o Yes o No	
3. Are you or is your company currently listed on the Debar List of the Directorate of Defense Trade Controls, U.S. State Department?    http://www.pmddtc.state.gov/compliance/debar.html	o Yes o No	
4. Are you or is your company currently listed on the Specially Designated Nationals List of the Office of Foreign Controls, U.S. Treasury Department?  http://www.treas.gov/offices/enforcement/ofac/sdn	o Yes o No	
5. Are you or your company acting on behalf of any foreign government or your own government? Are you A commercial firm (including its subsidiary and parent firms, and other subsidiaries of the same parent) that is wholly owned by, controlled by, or acting on behalf of any foreign government, including your own government?	o Yes o No	
Specify the End Use for this product:	
What is the Ultimate Destination of this product?	
6. ENC License Exception Statement Applies to Category 5 Only: Mouser Electronics hereby notifies the Buyer that products distributed by Mouser under the Encryption Commodities and Software (ENC) license exception are subject to section 740.17 paragraph (a)(1) of the Export Administration Regulations (EAR) of the United States of America.  Which further stipulates that any encryption item produced or developed with an item exported or re-exported under paragraph (a)(1) is subject to the EAR and requires review and authorization before any sale or transfer outside of the private sector end-user that developed it.  Further Buyer certifies that end-use is for internal “development” or “production” of new products.

By signing this document the person listed below acknowledges and accepts the restrictions described in section 740.17 paragraph (a)(1) of the Export Administration Regulations (EAR) of the United States of America.	

Signature of person authorized to sign on behalf of the company.
Signature	Date
	
Printed Name
	Title

QS-FM-010-7		5342579		231786487				10/06/14