EXPORT COMPLIANCE DECLARATION

FOR PRODUCTS TO BE EXPORTED TO […….specify country…….]

The following information is required to enable the Buyer to comply with all applicable export control and
international economic sanctions, laws and regulations
Project: ________________________________________________________
Name of Supplier: ________________________________________________
Address of Supplier: ______________________________________________________________________________
Country of incorporation of Supplier: _________________________________

Description of the item(s): ________________________________________________________________________

Code of the item(s): _____________________________________________________________________________
Harmonised System or Combined Nomenclature Code of the item(s): ______________________________________

A) EU Export Control section

A.1) Is/are your item(s) (or any component thereof) “dual-use item(s)” pursuant to Regulation (EC) No. 428/2009, as
per the latest available version?
Yes No
If yes, please indicate Control list No.: ____________________________________________________________ (*)

A.2) Is/are your item(s) (or any component thereof) listed in any other EU regulation establishing export control
restrictions?
Yes No
If yes, please indicate the applicable export control regime (e.g.: dangerous chemicals, drug precursors, ozone depleting
substances, etc.) and Control list No.: _____________________________________________________________ (*)

A.3) Is/are your item(s) (or any component thereof) included in any national list of military goods?
Yes No
If yes, please indicate number and category of military goods: __________________________________________ (*)

A.4) Is/are your item(s) (or any component thereof) listed item(s) as an effect of EU regulations concerning restrictive
measures under Article 215 TFUE (EU sanctions) against the country of destination specified in the heading?
Yes No
If yes, please indicate the applicable EU Regulation (e.g.: Council Regulation (EU) No 36/2012 concerning restrictive
measures in view of the situation in Syria, Council Regulation (EU) 2016/44 concerning restrictive measures in view of
the situation in Libya, etc.) and Control list No.: _______________________________________________________ (*)

THIS DECLARATION MUST BE COMPLETED AND SIGNED BY THE SUPPLIER AND

RETURNED TO BUYER.
IF APPLICABLE, PLEASE INCLUDE A COPY OF YOUR EXPORT LICENSE.

(*) If needed, information may be provided in annex to this declaration.

MOD-PRG711-01B Is.02
 EXPORT COMPLIANCE DECLARATION
FOR PRODUCTS TO BE EXPORTED TO […….specify country…….]
The following information is required to enable the Buyer to comply with all applicable export control and
international economic sanctions, laws and regulations
(*) If needed, information may be provided in annex to this declaration.

B) U.S.A. Export Control section

B.1) Is/are your item(s) (or any component thereof) subject to the U.S.- Export Administration Regulations (EAR)?
Yes No
If yes, please indicate the Export Control Classification Number (ECCN): ___________________________________
(*)

B.2) Is/are your item(s) (or any component thereof) subject to the EAR controlled pursuant to ECCN 5A002 or
5D002?
Yes No
If yes,
 is Licence Exception ENC [EAR §740.17(b)(3)] applicable? Yes No
 is Licence Exception ENC [EAR §740.17(b)(2)] applicable? Yes No
 is Licence Exception ENC [EAR §740.17(b)(1)] applicable? Yes No
 is Licence Exception ENC [EAR §740.17(a)] applicable? Yes No

B.3) Is/are your item(s) (or any component thereof) the foreign direct product of U.S.-origin technology or software
that requires a written assurance as a supporting document for a license?
Yes No
If yes, please indicate the relevant reference: ________________________________________________________ (*)

B.4) Is/are your item(s) (or any component thereof) subject to the International Traffic in Arms Regulations (ITAR)?
Yes No
If yes, please indicate the United States Munitions List (USML) class. No.: __________________________________
(*)

C) Other countries Export Control section

C.1) Is/ are your item(s) (or any component thereof) subject to Export Regulations of other countries?
Yes No
If yes, please specify: ____________________________________________________________________________ (*)

I hereby certify that the information provided herein is accurate and complete. I undertake to promptly inform the Buyer
in writing if this information changes.
Date / location _____________________________________ Signature ________________________________
Name and title of the Supplier’s employee compiling this declaration __________________________________________

MOD-PRG711-01B Is.02