U.S. DEPARTMENT OF COMMERCE
BUREAU OF INDUSTRY AND SECURITY

FORM BIS-711
Information furnished 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.

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DATE RECEIVED (Leave Blank)

1. Ultimate Consignee

City
Address Line 1
Address Line 2
Country
Postal Code
Telephone or Fax

2. Disposition or Use of Items by Ultimate Consignee Named in Block 1

We certify that the items:

A. 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. B. Will be processed or incorporated by us into the following product(s):

to be manufactured in the country named in Block 1 for distribution in:

C. 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:

D. Will be reexported by us in the form in which received to: E. Other (describe fully)

NOTE: If BOX (D) is checked, acceptance of this form by the Bureau of Industry and Security as a supporting document for license applications shall not be construed as an authorization to reexport the items to which the form applies 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

A. The nature of our usual business is:
B. Our business relationship with the U.S. exporter is:

and we have had this business relationship for:

year(s)

4. Additional Information

5. Assistance in Preparing Statement

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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 the representations made in this statement or contrary to Export Administration Regulations.

6. Signature of Official of Ultimate Consignee

Name of Official
Title of Official
Date (mm/dd/yyyy)
Signature of Official

Clear

5 + 6 =

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