Letterhead of the Consignee/End-user in the country of destination

END-USE DECLARATION
(goods which could be used for torture – consignee*)/end-user*) undertaking)

1. Czech exporter:___________________________________________________________
(name and address)___________________________________________________________

2. Consignee:________________________________________________________________
(name and address)___________________________________________________________

3. End-user:________________________________________________________________
(name and address)___________________________________________________________

4. The goods supplied:________________________________________________________

(description, quantity, value)____________________________________________________
___________________________________________________________________________

5. Purpose for which the goods are to be used:____________________________________

___________________________________________________________________________
___________________________________________________________________________

6. Specific location of the goods________________________________________________

(address where the goods will be used or based-if different from (1) or (2))_______________
___________________________________________________________________________
*)
The goods are to be used for our own use.
The goods are intended for stock to be held against future orders and will not be re-exported
*)

or sold for export or otherwise transferred from the country where we are based.

We certify that the goods will not be used for the purpose of capital punishment or for the
purpose of torture or other cruel, inhuman or degrading treatment or punishment.

___________________________________________________________________________
(Place and date) (Type or print name and title of authorized official)

__________________________________________________________________________________________
(Original signature and rubberstamp)

*)
use only the appropriate option