Scribd
Upload
313 views1 page

EUC NewForm 1

Mouser Electronics requires customers to complete an end-user certificate form providing company/individual information and certifying the end-use and destination of products will not violate US export laws. The form requests the customer's name, address, whether they have ever been convicted of export law violations, and if they are listed on any restricted party lists. It also requires specifying if the product use is military or civilian, its end-use application, and destination country. The signed and completed form must be scanned and emailed back to Mouser to avoid delays in order shipments.

Uploaded by

احمد الخواص
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
313 views1 page

EUC NewForm 1

Mouser Electronics requires customers to complete an end-user certificate form providing company/individual information and certifying the end-use and destination of products will not violate US export laws. The form requests the customer's name, address, whether they have ever been convicted of export law violations, and if they are listed on any restricted party lists. It also requires specifying if the product use is military or civilian, its end-use application, and destination country. The signed and completed form must be scanned and emailed back to Mouser to avoid delays in order shipments.

Uploaded by

احمد الخواص
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 1

Mouser Electronics, Inc.

Customer End-User Certificate


Complete the form. Print and sign the form. Scan and e-mail back to the person who sent you this form or Fax the form
to V or e-mail to [email protected] . Please note that incomplete, illegible or non-specific answers will delay order
shipments.
Company or Individual Information.
Name or Company Name DUNS, Federal ID or SSN

Address Web Address:

City State Country Postal Code

1. Have you or has your company ever been convicted of violating U.S. Export Laws and
Yes No
Regulation? If Yes, provide details below.

2. Are you or is your company currently listed on the Denied Person List, Unverified List or
Yes No
Entity List of the Bureau of Industry and Security, Department of Commerce?

3. Are you or is your company currently listed on the Debar List of the Directorate of
Yes No
Defense Trade Controls, U.S. State Department?

4. Are you or is your company currently listed on the Specially Designated Nationals List of the
Yes No
Office of Foreign Controls, U.S. Treasury Department?

5. Will this product be used for Military or Civilian purposes? Military Civilian
Specify the End-Use for this product by name or its application and if military or civilian:

What is the country of Ultimate Destination of this product?

Signature of person or person authorized to sign on behalf of the company.


Signature Date

Printed Name Title

Order Information (Mouser Use Only)


Picklist or Invoice Number Customer Number Date
263890566 610316D 01/23/23
CUST. P.O.: 27884536
Mouser Part Numbers with ECCN
781-SUP90P06-09L-E3 ECCN:EAR99

TCEX-FM-001-2 7/5/2022

You might also like