OLYMPUS EUROPA SE & Co.

KG
Amsinckstraße 63, 20097 Hamburg, Germany
Telephone: +49 40 23773-0
e-mail: info@olympus-europa.com website: www.olympus.com

Olympus End User Declaration

As part of the Export Control requirement, please fill out the information below and return it to
the originator so we can proceed with your order or enquiry.
Please complete all sections even if purchaser and End User are the same organisation.

Section 1 – Purchaser
Company Name & Address PO Ref:

Reseller?
Yes or
Please No
Select

Section 2 - End User

Company Name & Address (website if existent) Country of Equipment Destination

Section 3 – Use of Purchased Goods

Please set out the specific purposes for which the goods will be used by the end-user.
(e.g. which products will be inspected or analysed / in which branch will the goods be used)

Section 4 - Declaration

I declare that the above information is true and correct.

Sign here:
Authorised Representative

Date:

Print name:
Authorised Representative

Job Title:
Authorised Representative

______________________________________________
Place of Business: Hamburg, Commercial register: Amtsgericht Hamburg HRA 116518
Registered office and address for services as above. #DOC-18-01618 V.2.2