PEMERINTAH KABUPATEN KARANGASEM

DINAS KESEHATAN
UPTD LABORATORIUM KESEHATAN
Jalan Diponegoro No. 64, Amlapura. Telp. (0363) 4301412
Email : karangasemlabkes@gmail.com

Certification to be completed by End-User Only –End-User Certification

As the end-user of a product or other item(s)(software, technology, service) to be supplied to us directly by Thermo Fisher Scientific Inc. or one of its
subsidiaries / business units (“Thermo Fisher”) or to be supplied to us by a re-seller who has purchased the productfrom Thermo Fisher, I/we
understand that delivery may take place only after Thermo Fisher has received specificinformation regarding our intended end-use of the product(s).
This information is needed to help assure compliancewith the export laws of various countries (including but not limited to those of the United States
and the European Union).
Order/Reference
no.
Item name(s) ICE 3500 and related Optional accesories

A) We certify and warrant that the item(s) as ordered, will not be used, directly or indirectly, in any of the followingrestricted or prohibited
activities*:
i. Nuclear explosive activities
ii. Unsafeguarded nuclear activities
iii. Safeguarded and unsafeguarded nuclear activities related to facilities for
1. chemical processing of irradiated special nuclear or source material;
2. production of heavy water;
3. separation of isotopes of source and special nuclear material; or
4. fabrication of nuclear reactor fuel containing plutonium
Restricted rocket systems (including ballistic missiles, space launch vehicles and sounding rockets) and unmanned aerial
iv.
vehicles (including cruise missiles, target drones and reconnaissance drones) end-uses
Design, development, production, stockpiling, or use of chemical or biological weapons in or by any country or destination,
v.
worldwide
vi. Maritime nuclear propulsion
B) Describe the ultimate End-Use (specific activities for which you will use Thermo Fisher supplied product(s)):
Please describe the end-use with as much detailas possible. Vague or general end-use descriptions may lead to requests for additional information
and delays. “For research”, “for lab use”, “to test materials” alone are too general and not detailed enough.

For heavy metal in enviromental analysisi, metals contaminant in clean water analysis

C) End-User Information
End-User Company Name (legal entity name): Laboratorium Kesehatan Daerah (Regional Health Laboratory) in karang Asem
Department, faculty, school, laboratory, or Enviroment Laboratorium
other specific function within the organization,if
applicable:
End-User Street Address: Diponegoro No. 64
City: Karang Asem State: Bali
Country: Indonesia Postal Code: 80881
End-User Web URL: http://dinkes.karam=ngasemkab.go.id
Is your company/organization a “military end-user” as described No: √
in the U.S. Export Administration Regulation, Part 744.17 and EU Yes:
Regulation 2021/821 Article 4 latest version
D) End-User address (physical facility or factory location where the items will ultimately be used, if different from C):

The undersigned certifies that the information submitted is true and correct.

Signature: ………… Company Stamp:

Name (printed clearly): NI PUTU DIAH SUSMAYANI, SKM

Title/Position: Head Of Regional Health Laboratory in Karangasem

Date: 25 April 2022

Email: karangasemlabkes@gmail.com

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* For items subject to the US Export Administration Regulations (EAR) see 15 CFR §744 Last updated on September 14, 2021