itar general statement of assurance

To be reproduced on customers corporate letterhead

To be reproduced on customers corporate letterheadPlease include name, address, phone/fax emailPEI-Genesis

QA / Trade Compliance Dept

2180 Hornig Road

Philadelphia, PA 19116 USA

Subject: General Statement of Assurance

We, (your companys name) acknowledges that the commodities, software and/or technologies that we have been/will be purchased from PEI-Genesis may be subject to export, re-export or other restrictions to any destination, end-user, or for any end use prohibited by the laws of the United States or any other applicable law where such law does not conflict with the laws of the United States.

(your companys name) further warrants and agrees to abide by all applicable laws and regulations relating to the use, transfer, export, re-export, or resale of commodities, software and/or technology unless such use, transfer, export, re-export, or resale is specifically authorized by a government agency with the export authority over the items purchased or ordered from PEI-GenesisEnd use of product(s) Indicate yes or no in each category

Commercial end use: Yes NoMilitary End use:

Yes No

Distributor/Broker Yes No

Country(s) of export/re-export if products are resold (indicate one of the following): None

Country(s) list ____________________________________________________

Worldwide excluding Embargoed Countries

Billing company and address if different from letterhead:______________________________________________________________________________

______________________________________________________________________________

Company website (if available): _____________________________________________________

Type of industry (e.g. telecommunications) ____________________________________________

If we are unable to fulfill the above certifications, or if any of the above details change, we will advise PEI-Genesis of the change in writing before placing any further orders.

The undersigned acknowledges acceptance of this statement of assurance and certifies that the information submitted is true and correct.

Signature of authorized representative: ___________________________________________Name (printed): ________________________________________________________________

Title (printed): _________________________________________________________________Date signed (certificate valid for 4 years): __________________________________________

PEI Genesis Document 500.11.11.0

_1459930878.unknownAttribute VB_Name = "ThisDocument"Attribute VB_Base = "1Normal.ThisDocument"Attribute VB_GlobalNameSpace = FalseAttribute VB_Creatable = FalseAttribute VB_PredeclaredId = TrueAttribute VB_Exposed = TrueAttribute VB_TemplateDerived = TrueAttribute VB_Customizable = TrueAttribute VB_Control = "TextBox16, 8, 0, MSForms, TextBox"Attribute VB_Control = "TextBox15, 7, 1, MSForms, TextBox"Attribute VB_Control = "TextBox14, 6, 2, MSForms, TextBox"Attribute VB_Control = "TextBox112, 5, 3, MSForms, TextBox"Attribute VB_Control = "TextBox13, 4, 4, MSForms, TextBox"Attribute VB_Control = "TextBox111, 3, 5, MSForms, TextBox"Attribute VB_Control = "TextBox12, 2, 6, MSForms, TextBox"Attribute VB_Control = "TextBox11, 1, 7, MSForms, TextBox"Attribute VB_Control = "TextBox1, 0, 8, MSForms, TextBox"Private Sub CheckBox1_Click()

End Sub

Private Sub TextBox1_Change()ActiveDocument.SmartTags(1).SmartTagActions(1) _ .CheckboxState = True

End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub


End Sub

Attribute VB_Name = "ThisDocument"Attribute VB_Base = "1Normal.ThisDocument"Attribute VB_GlobalNameSpace = FalseAttribute VB_Creatable = FalseAttribute VB_PredeclaredId = TrueAttribute VB_Exposed = TrueAttribute VB_TemplateDerived = TrueAttribute VB_Customizable = TrueAttribute VB_Control = "TextBox16, 8, 0, MSForms, TextBox"Attribute VB_Control = "TextBox15, 7, 1, MSForms, TextBox"Attribute VB_Control = "TextBox14, 6, 2, MSForms, TextBox"Attribute VB_Control = "TextBox112, 5, 3, MSForms, TextBox"Attribute VB_Control = "TextBox13, 4, 4, MSForms, TextBox"Attribute VB_Control = "TextBox111, 3, 5, MSForms, TextBox"Attribute VB_Control = "TextBox12, 2, 6, MSForms, TextBox"Attribute VB_Control = "TextBox11, 1, 7, MSForms, TextBox"Attribute VB_Control = "TextBox1, 0, 8, MSForms, TextBox"Private Sub CheckBox1_Click()

End Sub


End Sub

itar general statement of assurance

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