Return a Signed Copy of the Completed Document To

Dear Customer,

As a requirement for a camera repair or replacement, we are obligated by the U.S. Department of Commerce to collect certain information and/or documentation related to the end use of FLIR Maritime 9 Hz products. This document is designed to assist you in providing this data to us.

Return a signed copy of the completed document to

If this product is being used or will be used by a military end-user (defined below) or incorporated into a military commodity, please contact us immediately. Additional information will be required and FLIR Maritime will assist in obtaining the appropriate authorisations for the U.S. Government.

Thank you,

FLIR Global Trade Compliance

FLIR Maritime Service 9Hz End Use/End User Statement

Section 1 – PRODUCT INFORMATION
Notification Number / Click here to enter Notification Number /
Part Number / Click here to enter Part Number /
Product Description / Click here to enter Product Description /
Serial Number / Click here to enter Serial Number /
Section 2 - END USER INFORMATION AND END USE OF THE PRODUCT
End User Name / Click here to enter End User Name
End User Full Address / Click here to enter End User Address Details
TICK SELECTION
Military End User?
(national armed services, including army, navy, marine, air force, coast guard; national guard; national police; government intelligence or reconnaissance organizations; or any person or entity whose actions or functions are intended to support military end-uses) / ☐ Yes ☐ No
Incorporated into a Military Commodity? / ☐ Yes ☐ No
Military End Use?
(meaning incorporation into a military item described on the U.S. Munitions List or on the Wassenaar Arrangement Munitions List; or to commodities classified under any U.S. Commerce Control List “600” series ECCN, ECCN ending in “A018,” or ECCN “0A919;” or for the use, deployment or production of military commodities (regardless of country of origin) that are described on the U.S. Munitions List or the Wassenaar Arrangement Munitions List,or that are classified under any U.S. Commerce Control List “600” series ECCN, or ECCN ending in “A018,” or ECCN “0A919.”) / ☐ Yes ☐ No
Detailed description of the intended end use of the product (how will the equipment be used?)provide comprehensive description of intended end-use / Click here to enter detailed description
Integration/installation details
advise if product is being integrated into a higher-level item or will be installed onto a platform such as a pole, rooftop, vessel, aircraft, or vehicle / Click here to enter Integration/Installation details
Signature of person completing this form
I certify that the information provided herein is true, complete and accurate to the best of my knowledge. I also understand that these commodities are classified for export control purposes under Export Control Classification Number (ECCN) 6A993.a and that they may not be sold, retransferred or re-exported without first obtaining the appropriate authorization.
Name: / Click here to enter First Name & Last Name /
Signature:
Title: / Click here to enter Title /
Company Name: / Click here to enter Company Name /
Date: / Click here & use drop down to enter date /
4210053 Rev. B / 24/10/2017