Please Check If Providing Manufacturer Information: ( )

End User Certification Form

Export of this commodity is subject to the United States Government Export Administration Regulations. Please complete, sign, and return this certification so we may review your purchase. If the UML product purchased is being used in the manufacture of some other product by other than the Purchaser or End User, please note the complete address and contact information on manufacturer’s letterhead.

Please check if providing manufacturer information: ( )

1.  Purchaser Information: End User Information:

Company: Click here to enter text. / Company: Click here to enter text.
Address: Click here to enter text. / Address: Click here to enter text.
City/Province: Click here to enter text. / City/Province: Click here to enter text.
Country/Postal: Click here to enter text. / Country/Postal: Click here to enter text.
Telephone/E-Mail: Click here to enter text. / Telephone/E-Mail: Click here to enter text.
Contact Name: Click here to enter text. / Contact Name: Click here to enter text.
+Company Web Address: Click here to enter text. / +Company Web Address: Click here to enter text.

+ If no web site available, please provide either a brochure or detailed company information on company letterhead.

2.  PO Number: Click here to enter text. PO Date: Click here to enter a date.

3.  Commodity to be purchased: Click here to enter text.

4.  Please provide a complete and detailed statement of the activities and operations to be performed using the UML Product(s). Click here to enter text.

5.  SELECT ONE: ( ) Military End Use ( ) Civil End Use

6.  Click here to enter text. (Your Company Name) certifies to the University of Massachusetts Lowell that the products being purchased/ordered will not be used in the design, development, production or use of any rocket systems or unmanned air vehicles capable of a range of at least 300 kilometers; will not be used in any design, development, production or use for chemical, biological or nuclear applications; and will not be diverted to any country, company or individual that is prohibited by the U.S. Government.

7.  Signature of Authorized Company Officer

Name (Printed): Click here to enter text. Date: Click here to enter a date.

Title: Click here to enter text.

Signature:

PLEASE COMPLETE & RETURN BY FAX TO ELAINE MAJOR AT +1 978-934-6012

End User Certification Form rev 8-28-12