FORM BIS-711
FORM APPROVED UNDER OMB
CONTROL NO. 0694-0021, 0694-0093
DATE RECEIVED
(Leave Blank)
U.S. DEPARTMENT OF COMMERCE
BUREAU OF INDUSTRY AND SECURITY
Information contained herewith 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.
STATEMENT BY ULTIMATE CONSIGNEE AND PURCHASER
1. ULTIMATE
CONSIGNEE
ADDRESS
LINE 1
ADDRESS
LINE 2
CITY
COUNTRY
POSTAL
CODE
TELEPHONE
OR FAX
2. DISPOSITION OR USE OF ITEMS BY ULTIMATE CONSIGNEE NAMED IN BLOCK 1
We certify that the items: (select the appropriate box below)
Will be used by us (as capital equipment) in the form in which received in a manufacturing process in the country named in Block 1 and will not be reexported or
incorporated into an end product.
A.
Will be processed or incorporated by us into the following product(s)
B.
to be manufactured in the country named in Block 1 for distribution in
C.
Will be reexported by us [in the form in which received] to
D.
Other (describe fully)
E.
Will be resold by us in the form in which received in the country named in Block 1 for use or consumption therein.
The specific end-use by my customer will be
NOTE: if box D is checked, acceptance of this form by the Bureau of Industry and Security as a supporting document for license application shall not be construed as an authorization to reexport the items
to which the formapplies unless specific approval has been obtained from the Bureau of Industry and Security for such export.
3. NATURE OF BUSINESS OF ULTIMATE CONSIGNEE NAMED IN BLOCK 1
The nature of our usual business is
A.
Our business relationship with the U.S. exporter is
B.
and we have had this business relationship for
year(s).
4. ADDITIONAL
INFORMATION
5. ASSISTANCE IN
PREPARING STATEMENT
STATEMENT OF ULTIMATE CONSIGNEE AND PURCHASER
We certify that all of the facts contained in this statement are true and correct to the best of our knowledge and we do not know of any additional facts which are inconsistent with the above statement. We
shall promptly send a supplemental statement to the U.S. Exporter, disclosing any change of facts or intentions set forth in this statement which occurs after the statement has been prepared and forwarded,
except as specifically authorized by the U.S. Export Administration Regulations (15 CFR parts 730-774), or by prior written approval of the Bureau of Industry and Security, we will not reexport, resell, or
otherwise dispose of any items approved on a license supported by this statement (1) to any country not approved for export as brought to our attention by means of a bill of lading, commercial invoice, or any
other means, or (2) to any person if we know that it will result directly or indirectly, in disposition of the items contrary to Export Administration Regulations.
6. SIGNATURE OF OFFICIAL
OF ULTIMATE CONSIGNEE
7. NAME OF
PURCHASER
SIGNATURE OF
PURCHASER
NAME OF
OFFICIAL
TITLE OF
OFFICIAL
NAME OF
OFFICIAL
TITLE OF
OFFICIAL
DATE (mmmm, dd, yyyy)
DATE (mmmm, dd, yyyy)
CERTIFICATION FOR USE OF U.S. EXPORTER - we certify that corrections, additions, or alterations
were made on this form by us after the form was signed by the (ultimate consignee) (purchaser).
(Ludlum Measurements, Inc., internal use only)
8. NAME OF EXPORTER
SIGNATURE OF PERSON AUTHORIZED TO CERTIFY FOR EXPORTER
9. VISUAL COMPLIANCE COMPLETED (Ludlum internal use only) (Ludlum internal use only) TITLE OF PERSON SIGNING
THIS DOCUMENT
DATE (mmmm, dd, yyyy)
We acknowledge that the making of any false statements or concealment of any material fact in connection with this statement may result in imprisonment or fine, or both and denial, in whole or in part, of
participation in U.S. exports and reexports.
Public reporting burden for this collection of information is estimated to average 15 minutes per
response plus one minute for record keeping, including the time for reviewing instrument, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducting this burden, to the Director of
Administratoin, Room 3889, Bureau of Industry and Security, U.S. Department of Commerce,
Washington, D.C. 20230, and to the Office of Management and Budget Paperwork Reduction Project
(0694-0021, 0694-0093), Washington, D.C. 20503. Notwithstanding any other provision of law, no
person is obligated to respond to nor shall a person be subject to a penalty for failure to comply with a
collection of information subject to the Paperwork Reduction Act unless that collection of information
displays a currently valid OMB Control Number.
501 Oak Street
P.O. Box 810
Sweetwater, Texas 79556
Website: http://www.ludlums.com
Phone: 325-235-5494
Phone: 800-622-0828 (USA)
Fax: 325-235-4672
E-Mail: export@ludlums.com
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