Global Trade Compliance

Screening Form

Rev. 3_2018-1-19

1.CustomerName and AddressInformation

Customer Name
Address
(P.O. boxes unacceptable)
Phone Number(s)
Website
State Owned or Controlled Enterprise, in Whole or in Part (Yes or No)

2.If additional Locationswill receive our items, please list them here

(Please add additional rows as necessary.)

Name / Address
(P.O. boxes unacceptable) / Phone Number(s) / Website

3.Customer’s Board of Directors and Leadership/Executive Team Information

This will be the Head of Department and the main Professor point of contact who is using the software.

(Please add additional rows as necessary.)

Board of Directors
Name / Position/Title
Leadership/Executive Team (e.g., CEO, CFO, COO, etc. or equivalent)
Name / Position/Title

4.Customer’s Ownership Information

This will be the local, state, government department or other organization that has management control of your institution.

(Please add additional rows as necessary.)

Owner Name / Address
(P.O. boxes unacceptable) / Phone Number / Website / Ownership
Percentage / State Owned or Controlled Enterprise, in Whole or in Part (Yes or No)

5.Customer’s Agent Information

AgentName / Address
(P.O. boxes unacceptable) / Phone Number / Website / What will the agent do as part of the transaction? (E.g. Purchasing, Import/Export, etc.) / State Owned or Controlled Enterprise, in Whole or in Part (Yes or No)
Europractice / Microelectronics Support Centre
Rutherford Appleton Laboratory
Chilton, Didcot
Oxfordshire, OX11 0QX
UK / +44 (0)1235 445327 / / Purchasing,
technical support / Yes

6.Description of Customer’s Business Activities and End-Use of our Items

6.1.Description of customer’s business activities:

6.2.Description of the customer’s end product and industry where end products are used:

6.3.Description of end-use of items received from our company:

7.Export Screening

7.1.Parties of Concern List

Are your Company, any Affiliates of your Company, or any End User(s) currently listed on any Denied/Restricted Parties Lists compiled by government agencies for the control of export transactions?

Yes or No
If yes, please provide the name of the entity/end user

By answering “Yes” to 7.1, you acknowledge that the products you are purchasing from us are covered by the United States Export Administration Regulations (EAR). You understand that some affiliates of your entity are listed on the Entity List of the United States EAR(see Supplement No. 4 to Title 15 Part 744) or of any sanctioned list of other international government agencies. You will not make available, directly or indirectly, any items purchased from us to any entity identified on various international government agency lists.

7.2.Foreign Corrupt Practices Act (FCPA) Compliance

7.2.1.Is any owner, director, executive, or individual with decision-making authority to purchaseour products and services a government official or employee?

Yes or No
If yes, please provide the name of the individuals and their government positions

7.2.2.Have there been any claims, litigation, or investigations, related to fraud, violations of any anti-corruption laws (including but not limited to the U.S. Foreign Corrupt Practices Act), or any other criminal act, against your Company, any affiliate Company, or any of the owners, directors, executives, or individuals with decision-making authority over our products and services?

Yes or No
If yes, please explain

7.3.Antiboycott Compliance

Does your Company or any End User Entities participate in any international boycott that is not sanctioned by the United States, including the Arab League boycott of Israel, or otherwise include in their contractual documentation any requests for us to agree to blacklist other companies/countries to discriminate based on race, religion, sex, national origin or nationality in violation of §760.2 of the United States Export Administration Regulations?

Yes or No
If yes, please explain

7.4.Diversion Risk

By entering “yes” below,you acknowledge that you will export, re-export, or transfer our products in accordance with U.S. Export law.

Yes or No
If you are unable to acknowledge, please explain

7.5.Nuclear & Missile, Chemical & Biological Weapons Screen, and Aerospace Research

Do you know, or have reason to know, that our products will be used directly or indirectly in the design, development, production, stockpiling, or use of chemical, biological or toxinsweapons, or that they will be used directly or indirectly in any nuclear activities1, heavy water manufacturing, missile related activities, rockets systems,Unmanned Aerial Vehicles, or aerospace research?

Yes or No
If yes, please explain
  1. Nuclear activities include but not limited to the following: development, manufacture, use or storage of nuclear weapons, fuel or nuclear source materials, research on nuclear fusion, development, manufacture, use or storage of nuclear reactors or parts and attachments therefor, processing of nuclear fuel, or reprocessing of nuclear fuel.

7.6.Conventional Weapon and Embargo Screen

Do you know, or have reason to know, that our tools or items produced from our tools will be exported to the following countries?

Azerbaijan Republic, Bolivarian Republic of Venezuela, Central African Republic, Democratic People's Republic of Korea, Democratic Republic of Congo, Federal Republic of Somalia, Islamic Republic of Afghanistan, Islamic Republic of Iran, Lebanese Republic, People's Democratic Republic of Algeria, Republic ofArmenia, Republic of Belarus, Republic of Côte d'Ivoire, Republic of Cuba, Republic of Iraq, Republic of Liberia, Republic of Sudan, Republic of South Sudan, Republic of the Union of Myanmar, Republic of Yemen, Republic of Zimbabwe, Republikay'u Rwanda, Russian Federation, State of Eritrea, State of Libya, and Syrian Arab Republic

Yes or No
If yes, please specify which country or countries

7.7.Military Activities

7.7.1.Does your Companybelong to or is affiliated with any military organization?

Yes or No
If yes, please specify which military organization

7.7.2.Does your Company plan to use our products directly or indirectly in design or production activities with a military or defense organization or an entity controlled by a military or defense organization?

Yes or No
If yes, please explain

Note: Answering “No” indicates you acknowledge that the products you are purchasing from our company are intended for civil end use.

8.Affirmation

By signing this form, the individual affirms that the information provided above is true and correct. Inaddition, by signing below, your Company and End User(s) will not knowingly export directly or indirectly, any United States origin technical data or software acquired from our company and our subsidiaries or any direct product of that technical data, for which the United States government or any agency thereof at the time of the export requires an export license or other government approval, without first obtaining such a license or approval, when required by applicable United States law. (Reference: U.S. Export Administration Regulations, Part 740.6.)

The Signer should be an employee of the Customer with knowledge and authorization to affirm the above representations.

Name of individual completing questionnaire
Company name
Position/title
Signature
Date

THANK YOU FOR YOUR DUE DILIGENCE IN COMPLETING THIS IMPORTANT EXPORT SCREENING FORM.

Coventor, Inc., a Lam Research company, 1000 CentreGreen Way, Suite 200, Cary, North Carolina 27513Page 1 of 6