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STATEMENT OF ULTIMATE DESTINATION

In order to comply with U. S. Department of Commerce, Bureau of Industry and Security, rules and regulations,
we must gather end-user information prior to accepting your order. Information furnished in this document is
subject to the provisions of Section 12(c) of the Export Administration Act of 1979, as amended 50 U.S.C.
app 2411(c) and its unauthorized disclosure is prohibited by law.

PLEASE PROVIDE ALL OF THE INFORMATION REQUESTED IN THE FOLLOWING SECTIONS

1. Model numbers of LI-COR instruments requested:

2. Contact information for your organization:

A. Your Name B. Official Name of Your Organization

C. Address Line 1 D. Address Line 2

E. City F. State/Province

G. Country H. Postal Code

I. Telephone J. E-mail address

3. Nature of request for LI-COR instrument named in Section 1:

We plan to resell this instrument (Proceed to Section 4 and supply Ultimate Consignee Information)

We will use this instrument in our own research.

Short description of research:

4. Name of Ultimate Consignee/End User (if different from Section 2):

A. Name B. Official Name of Organization

C. Address Line 1 D. Address Line 2

E. City F. State/Province

G. Country H. Postal Code

I. Intended use of the item by the ultimate consignee:

By signing this document, we certify that all facts contained in this statement are true and correct to the best of our knowledge, and that
we do not know of any additional facts that are inconsistent with the above statements. We certify that we will follow all U.S. Export
Administsration Regulations in that we will not export, re-export, resell or otherwise dispose of the specified LI-COR instrument to any
country not approved for export, or to any person(s) that are contrary to U.S. regulations. We acknowledge that this form may be
reviewed by the US Department of Commerce for validation purposes.

Signature

Title of Person Signing this Document Date