Declaration Form for USML Category Purchases

Customer/WD Name:________________________________________________________________
Purchase Order/RFQ No.:__________________________ DDTC Registration #_________________
Please check the box that best describes your customer for this order:
U.S. Government/Stock (proceed to Section 1)
Export (proceed to Section 2)

Broker (proceed to Section 3)

OEM (proceed to Section 4)

1) U.S. Government Orders / Stock for U.S. Government (check one)

1a) Name of U.S. Government purchasing agency: ________________________________________________
1b) Stock for future sales to: _________________________________________________________________
Proceed to Section 5
____________________________________________________________________________________________
2) Export
2a) Will you obtain Export License?
Yes
No
2b) Export License Number (if you have obtained for this order):______________________________________
NOTE: A copy of the Export License must be provided to CEN prior to shipment. Export License can be
obtained from U.S. State Department by completing DSP-5 application.
Proceed to Section 5
____________________________________________________________________________________________
3) Broker
3a) Broker Name:_______________________________ City and State:______________________________
Yes (Enter Registration #_________)
No
3b) Is Broker registered with the U.S. State Department?
3c) Is broker purchasing parts for export?
Yes
No
Yes
No
3d) Will Broker obtain Export License?
3e) Export License Number (if broker has already obtained) _________________________________________
NOTE: A copy of the Export License must be provided to CEN prior to shipment.
Proceed to Section 5
___________________________________________________________________________________________
4) OEM
4a) Name of OEM_______________________________

Address__________________________________
Proceed to Section 5
___________________________________________________________________________________________
5) End User Information
5a) End User Name:___________________________________________________________________________
5b) End User Address:_________________________________________________________________________
Proceed to Section 6
5c) Country of Ultimate Destination:__________________________
___________________________________________________________________________________________
6) COMPLETE THIS SECTION FOR ALL CATEGORIES:

I hereby declare to best of my knowledge that all information provided above is true and correct.
Print name and title:__________________________________________________________________________
Signature:____________________________________________
For Office Use Only:
AM/OR Dept. Approval_____________________________
Export Dept. Review_______________________________
Export Dept. Approval______________________________
FORM 90

Date:____________________________
C.E. Niehoff & Co.
2021 Lee Street
Evanston, IL. 60202
Tel: 847-866-6030
Fax: 847-570-0127
Rev. 2 (04/05)