DECLARATION OF COMPLIANCE

We, the undersigned, hereby declare that we are in compliance with the United States Department of Commerce, Bureau of
Industry and Security requirement for disclosure of end use prior to the export of goods as specified in the Code of Federal
Regulations, Title 15 Parts 730 through 774. These regulations require exporters of U.S. manufactured goods to fully exercise their
responsibility to know their customers, to understand the uses to which the Exporters’ products will ultimately be put, and to
determine the final end use destination of their products.

DISCLOSURE OF END USER and END USE

We hereby verify the products purchased from PCB Piezotronics, Inc. will not be applied or diverted to any end user or end use, or
destination that is in conflict with the US Export Administration Regulations (U.S. EAR) and the International Traffic and Arms
Regulations (ITAR)”.

We also certify that products purchased will not be used for nuclear explosive activities as outlined in section 744.2 of the U.S.EAR,
or for chemical or biological weapon applications as outlined in the U.S.EAR, Section 744.4.
In addition, we certify that the end use of these products will not be for missile, missile and rocket launch, or unmanned vehicle
system applications as outline in the U.S.EAR section 744.3.
We further verify that the information listed below is accurate.
Company Name: ______________________________________________
Company Address: ______________________________________________
______________________________________________
______________________________________________
Point of contact: ______________________________________________
Point of Contact telephone # and Email: ______________________________________________

Are you the Final End User? (Circle one) Yes No Are these items for resale? (Circle one) Yes No
If for resale provide the following information:
Final End User of Product- Company: _____________________________________________
Final End User Physical Address: _____________________________________________
(Complete Address, No PO Box) _____________________________________________
_____________________________________________
Final End Use Country: _____________________________________________
Detailed Description of Application: ___________________________________________________________________
(How Product will be used by End User) ___________________________________________________________________
___________________________________________________________________

It is understood that a purchase agreement with PCB Piezotronics, Inc., is not binding and cannot be processed without a fully
completed and signed Declaration of Compliance. Incomplete forms will be returned.

By: _________________________________________ For: ________________________________________

(Signature) (Type or Print Organization Name)
Name: ______________________________________
(Type or Print Legibly) Date: _____/_____/_____
Title: _______________________________________

Corporate Headquarters
3425 Walden Avenue, Depew, New York 14043-2495
SM007 REV D Phone: 716-684-0001 Fax: 716-684-0987
Email: sales@pcb.com
Web: www.pcb.com
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