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End Use Declaration - Russia Sanctions v.1.0

This document is an export controls form that must be completed by Freudenberg customers where the end-use or end-user of products is located in Russia or unknown. The form requires customers to provide information about the end-user, item details, and certify compliance with export regulations. By signing, customers agree to not export or use Freudenberg goods for prohibited purposes and certify that all information provided is accurate. Failure to comply with regulations could result in order cancellation or legal action.

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442 views

End Use Declaration - Russia Sanctions v.1.0

This document is an export controls form that must be completed by Freudenberg customers where the end-use or end-user of products is located in Russia or unknown. The form requires customers to provide information about the end-user, item details, and certify compliance with export regulations. By signing, customers agree to not export or use Freudenberg goods for prohibited purposes and certify that all information provided is accurate. Failure to comply with regulations could result in order cancellation or legal action.

Uploaded by

masiclj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Export Controls Form – End-Use/End-User – Russian Oil & Gas Industry Sales

To support Freudenberg’s export controls and compliance requirements, Freudenberg requires that this Export Controls Form be completed
by all our customers where the ultimate end-use/end-user is located in the Russian Federation, or is not known.

Purchase agreements and items will not be provided until the form is accurately completed, signed and returned to your Freudenberg contact.
Thank you very much.

End-Use/End-User and Final Destination of the Goods

Company/Customer Contact
Name:
Country Location:
Street Address:
Phone Number:
E-Mail Address:

Item Description (include part


number and specifications):

Country of final destination of


the goods listed above (the final
end-use country):
Company/Contact Name if the
end-user is other than the
Company/Customer listed above
(if the same, enter “SAME” in this
field):
ECCN and Schedule B of the
customer’s item that will
incorporate Freudenberg’s item:
Detailed description of the
application and for the items use:

Customer agrees and expressly certifies that he/she:


A) Will not deliver (export, re-export or transfer) products purchased directly or indirectly from Freudenberg locations or through any
third party for end use directly or indirectly in Russia's energy sector for exploration or production from deepwater (greater than
500 feet), Arctic offshore, or shale projects in Russia that have the potential to produce oil or gas or if customer is unable to
determine whether the item will be used in such projects in Russia.
B) Confirms that Freudenberg items will not be incorporated into any items subject to the Export Administration Regulations per the
U.S. Departments of Commerce’s Final Rule: http://www.gpo.gov/fdsys/pkg/FR-2014-08-06/html/2014-18579.htm under the
specified ECCNs and Schedule B numbers listed in this rule.
C) Will not deliver (export or re-export) products purchased directly or indirectly through any third party to:
1. Cuba, Iran, North Korea, Sudan, or Syria, or any other country for which the United States maintains export controls,
export embargoes or other economic sanctions, except if necessary licenses for such export or re-export has been
obtained from the appropriate U.S. Government Agency (e.g., U.S. Bureau of Industry, Office of Foreign Assets
Control, Department of State). This provision applies equally to Freudenberg products ordered for new installation, as
well as for repair or replacement purposes.
2. Any prohibited individuals, entities or countries listed under the U.S. and European Union denied party lists and the
United Nations Security Council Resolutions.
D) Will not use Freudenberg goods for forbidden end uses, including: the development there of nuclear facilities not licensed by the
U.S. Government; chemical, biological, or nuclear weapons; rocket, missile or unmanned aircraft systems or terrorist activities.
E) Customer will abide by applicable U.S. Government export license requirements.
F) We will not export, re-export or otherwise transfer products to persons or entities designated on the above-referenced lists unless
authorized by the U.S. Government.

By providing my electronic signature below as an authorized representative of my company, I am verifying that we understand it is our
company’s responsibility to adhere to Export Administration Regulations, Department of Defense, Department of State, Department of
Treasury, and Department of Census regulations related to export transactions. In addition we understand that it is the responsibility of
our company to monitor prohibited end users, embargoed/sanctioned nations lists, and prohibited parties listings for updates that would
affect the course of business and compliance with these government regulations.

Any material omissions, misrepresentations, or misstatements by the customer in connection with the above certifications are grounds
for further action by Freudenberg, including but not Iimited to, cancellation of orders, denial of future business, and appropriate legal
action. Freudenberg may be required by applicable laws, or requested by appropriate law enforcement authorities, to report information
related to, or assist in the investigation of possible violations of U.S. export control laws.

I certify that:
1) I am authorized to sign on behalf of my company, and
2) That the Information provided in this document is true and correct.

------------------------------- ----------------------------------------------- -----------------------------------------------


Date Name Signature

Rev.1.0/Sept.2014

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