EXPORT CONTROL CLASSIFICATION DECLARATION FORM

EXPORT CONTROL CLASSIFICATION DECLARATION FORM
SUPPLIER LOGO/STAMP REQUIRED HERE
SECTION 1(a) - SUPPLIER INFORMATION (Supplier’s complete Name and Address (FOKKER ELMO Purchase Order Recipient))
Cage:
Name:
Address:
City/State:
Postal/Zip
Country :
Code:
SECTION 1(b) – SUPPLIER’S EXPORT CONTROL CONTACT INFORMATION
Name:
Position:
Tel.:
Fax :
Email:
SECTION 2 - ITEM/COMMODITY IDENTIFICATION
Name of the Item/Commodity,
brief description of the product
Supplier Part #:
FOKKER ELMO Part #:
(If P/N’s are known at time of request. If at RFQ/RFP/RFI stage, leave blank)
If you are US supplier continue to Section 4
SECTION 3 - NON-U.S. SUPPLIER INFORMATION
TO BE COMPLETED BY ALL NON-U.S. SUPPLIERS
Is the Item/Commodity subject to your National export control regulation? YES
NO
IMPORTANT - It is the supplier’s responsibility to check with their National Export Control authorities.
Was your Item/Commodity initially developed for a Civil/Dual-use or Military application?
Civil/Dual-use-item?
YES:
NO:
if yes, indicate Control List-No. (if applicable):
Military Equipment?
YES:
NO:
if yes, indicate Control List-No. (if applicable):
Remember: An item is either civil/dual-use OR military, NEVER both
SECTION 4 – U.S. ITEM/COMMODITY INFORMATION
TO BE COMPLETED BY ALL U.S. SUPPLIERS OR BY ALL NON-U.S. SUPPLIERS OF US ORIGIN
ITEMS/COMMODITIES,
I.E. PRODUCED OR MANUFACTURED IN THE US OR MANUFACTURED BY US COMPANIES
OR USING US COMPONENTS, TECHNOLOGIES, OR SOFTWARE
a) Is your Item/Commodity subject to U.S. regulations? YES
NO
IF YES, complete U.S. classification in SECTION 5a below
b) Is your Item/Commodity fully manufactured in the U.S.? YES
NO
IF YES, complete U.S. Manufacturer’s Name and Address in SECTION 5b below or
c) Are there components originating from the U.S. integrated in your item/commodity? YES
IF YES, COMPLETE SECTION 7 BELOW
FOKKER ELMO B.V. is a company of Fokker Technologies
Page 1 of 3
Form 5174 Issue 01
NO
SECTION 5a - U.S. CLASSIFICATION
EAR
YES
NO
if yes, indicate ECCN-No.:
or
ITAR
YES
NO
if yes, indicate USML classification No.:
If ITAR regulations apply, please specify whether,
the product is considered as Significant Military Equipment (§120.7 ITAR)? YES
the product is considered as Major Defence Equipment (§120.8 ITAR)?
YES
NO
NO
Remember: An item is either EAR OR ITAR, NEVER both
SECTION 5b – U.S. MANUFACTURER’S INFORMATION
Name and address of U.S. Manufacturer:
Name:
Address:
City/State:
Postal/Zip
Code:
Country:
SECTION 6 – CONTENT OF ITAR/EAR CONTROLLED ITEMS/COMMODITIES
This page applies to all NON U.S. suppliers whose Items/Commodities incorporate U.S. components.
Please extend this lists if there are more components
Please list the US content of your product, including all ITAR and EAR controlled parts
(CCL and EAR 99) (use Annex if necessary)
6
7
8
9
US Item/Commodity
(or US component
embedded in
Item/Commodity)
US Manufacturer
Part Type/Part #
ITAR or
EAR
9bis
10
% value Classification
of US
content
11
12
SME
MDE
SECTION 7 – THIRD COUNTRY LIMITATIONS
a) Has your Item/Commodity any content controlled by a third country
(neither your country nor U.S.)
YES
NO
b) If yes, are there limitations (e.g. sales territory, end-use) imposed by the third country
c) If yes, please specify: (use attachment if necessary)
FOKKER ELMO B.V. is a company of Fokker Technologies
Page 2 of 3
Form 5174 Issue 01
YES
NO
I hereby certify that the information provided herein is true, complete, and accurate.
Where the export, re-export or transfer of the item/commodity, by FOKKER ELMO or any of its customers, is subject to an export license, the issuance of such license shall be a condition precedent to this purchase order coming
into force. I shall provide FOKKER ELMO with a copy of any such license upon receipt. In the event that such license would be revoked, not renewed, invalidated, or otherwise not be effective for any reason, FOKKER ELMO
shall have the right to cancel this order immediately, by means of a registered letter.
I shall inform FOKKER ELMO, in writing, as soon as I will become aware of any change that may affect export control classification of the item/commodity described hereinbefore.
I am aware that prior to a purchase order coming into force, this “Export Control Classification Declaration” is to be filled out and
returned to FOKKER ELMO.
Date
Location
(DD/MM/YY)
Name and Title (supplier)
Name and Signature
of empowered Official
NOTES
(Section 2) Brief description of the product (e.g. backshell, wire, contact, connector, etc.),
Product type/part number as per Purchase Order, Specification, or catalogue reference. If you have several independent products, write “Refer-to-Table”
(Section 7) If the Item/Commodity subject to this declaration is non-US, please list all US content including FOKKER ELMO content embedded under De-Minimis. If you are a US supplier, providing this certificate for several line
items, please fill in one line per line item of US content. Please use an Annex if you have more line items.
FOKKER ELMO B.V. is a company of Fokker Technologies
Page 3 of 3
Form 5174 Issue 01