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End Consignee Statement / End Use Certification

Dear Sir/Madam:
will not use, transfer, export, and re-export, resell or otherwise dispose of any items purchased from Symmetry Electronics to any destination, end-user or for any end-use prohibited by the laws of the United States or any other applicable law where such law does not conflict with the laws of the United States; unless such use, transfer, re-export, resale or disposition is specifically authorized by a government agency with export authority over the items purchased or ordered by us from Symmetry Electronics
Ownership interest in the company is not held by a person(s) listed on the Office of Foreign Asset Controls (OFAC) Specially Designed Nationals List (SDN) or by Executive Order. Any subsequent designation of owners or employees will be reported to Symmetry Electronics.

End Use of Product(s)

If you selected "Yes", the End User Information section must be completed.

Country(s) of export/ re-export if products are resold

If none, please indicate "none".
This will help expedite the processing your form.
If we are unable to fulfill the above certifications, or if any of the above details given shall change at any time, we will advise Symmetry Electronics of the change in writing before placing any further orders.
* A new certification is required if the customer's name changes, or if the end user changes per order placed. Each certification expires 1 year after submission.
for this End Use Certificate, warrant the truthfulness of the information provided in this application.
Please type your First and Last Name