Mouser Electronics, Inc.

Customer End-User Certificate

Complete the form. Print and sign the form. Scan and e-mail back to the person who sent you this form or Fax the form
to V or e-mail to export@mouser.com . Please note that incomplete, illegible or non-specific answers will delay order
shipments.
Company or Individual Information.
Name or Company Name DUNS, Federal ID or SSN

Address Web Address:

City State Country Postal Code

1. Have you or has your company ever been convicted of violating U.S. Export Laws and
Yes No
Regulation? If Yes, provide details below.

2. Are you or is your company currently listed on the Denied Person List, Unverified List or
Yes No
Entity List of the Bureau of Industry and Security, Department of Commerce?

3. Are you or is your company currently listed on the Debar List of the Directorate of
Yes No
Defense Trade Controls, U.S. State Department?

4. Are you or is your company currently listed on the Specially Designated Nationals List of the
Yes No
Office of Foreign Controls, U.S. Treasury Department?

5. Will this product be used for Military or Civilian purposes? Military Civilian
Specify the End-Use for this product by name or its application and if military or civilian:

What is the country of Ultimate Destination of this product?

Signature of person or person authorized to sign on behalf of the company.

Signature Date

Printed Name Title

Order Information (Mouser Use Only)

Picklist or Invoice Number Customer Number Date
263890566 610316D 01/23/23
CUST. P.O.: 27884536
Mouser Part Numbers with ECCN
781-SUP90P06-09L-E3 ECCN:EAR99

TCEX-FM-001-2 7/5/2022