End Use / Ultimate Destination Form

Statement of Ultimate Consignee and Purchaser

In order to comply with U.S. Department of Commerce, Bureau of Industry and Security, rules and regulations, we must gather end-user information prior to accepting your order. Information furnished in this document is subject to the provisions of Section 12(c) of the Export Administration Act of 1979, as amended 50 U.S.C. app 2411(c) and its unauthorized disclosure is prohibited by law.

Please provide ALL of the information requested in the following sections:

1. Brief Description of Dultmeier Sales Parts Requested:

2. Contact Information for your Organization:

Your Name:

Customer # or Dultmeier Order #: Tax I.D.#:

Official Name of your Organization:

Address Line 1:

Address Line 2:

City:

State / Province:

Country:

Postal Code:

Telephone:

E-mail Address:

3. Nature of request for Dultmeier Sales part numbers named in Section 1:

We plan to resell these parts.

Our business relation with this company:

The Dultmeier customer agrees not to resell the U.S. product to the following countries: Cuba, Iran, Libya, North Korea, Sudan and Syria. If such a sale is contemplated, the customer agrees prior to export to obtain a U.S. export license pursuant to the U.S. Export Administration Regulations ("EAR").

**(Proceed to Section 4 and supply Ultimate Consignee Information)**

We will use this in our own company in the State / Country of:

Short Description of use:

4. Name of Ultimate Consignee / End User (if different from Section 2):

Your Name:

Official Name of your Organization:

Address Line 1:

Address Line 2:

City:

State / Province:

Country:

Postal Code:

Intended use of the item by the ultimate consignee:

Additional Comments:

YES We certify that all facts contained in this statement are true and correct to the best of our knowledge, and that we do not know of any additional facts that are inconsistent with the above statements. We certify that we will follow all U.S. Export Administration Regulations in that we will not export, re-export, resell or otherwise dispose of the specified Dultmeier Sales Parts to any country not approved for export, or to any person(s) that are contrary to U.S. regulations. We acknowledge that this form may be reviewed by the US Department of Commerce for validation purposes.