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Rev July 25, 2008

Please provide information specific to this quote/purchase.

All information is kept confidential to Rogers Corporation only.
Rogers Corporation reserves the rights to validate the end use and end user.
1. Date:


2. Rogers Customer Company Name and Full Address

Rogers Customer Contact Information


Contact Name________________________________




Email ______________________________________

3. Request For Quote/Purchase Order Number________________________________________________________


Are you: (a) OEM (in house/captive fabrication)

(b) Contracted Fabricator (direct sales to OEM)

(c) Fabricator for Contract Manufacturer (non-direct sales to OEM)

(d) Trading Company

If choose (a), (b) or (c), you can skip question 5 and continue on from question 6.

A: Ship To Company Name, Address and Contact

B: Fabricator/manufacturer Company Name, Address and Contact







Ship To Persons Name_________________________ Buyers Name__________________________________

Phone or email________________________________ Phone or email _________________________________
Buyers Signature_______________________________

If you are an OEM or a trading company representing the OEM,

(a) Describe your final products.

(b) Are these final products to be used in commercial applications or military applications?

(c) Which countries do you plan to distribute your final products to?

7. If you are a contracted fabricator, a fabricator for contract manufacturer, or a trading company representing either,
please state your product, name the OEM, your contact information at OEM, and the program where Rogers products are

8. We, _________________________, certify that the commodities being purchased by us will

not knowingly be resold, transferred or re-exported to the countries that are currently under
U.S. government export embargo, or into nuclear, missile, or chemical/biological weapon
applications. Furthermore, these commodities will not be resold, transferred or re-exported to
any person or entity who is currently on any of U.S. government denied party lists.
9. Print Name of Person Who Filled This Form __________________________________________
10. Signature _____________________________________
For Rogers Customer Service Use ONLY: EUS Log Number__________________________________