International End Use Certification Statement

INTERNATIONAL END USE CERTIFICATION STATEMENT AND REPAIRS RQUEST
It is Trijicon’s policy to request end-use and end-user information prior to exporting products from the United States. Acceptance of purchase orders and shipping of Trijicon products and/or technical data depend on verification of this information and may require prior authorization from United States Government. We ask that you complete and return the signed form as soon as possible. Please note that we cannot process your order until the completed document has been received.

Trijicon Product / Model Number

Serial Number

Country of Ultimate Destination

PURCHASER INFORMATION

Purchaser / Customer Name

Person Ordering Product

Full Name (First and Last)

Street Address

City

Country

Phone

END USER INFORMATION

End User Name

End User Contact

Full Name (First and Last)

Street Address

City

Country

Phone

End User Description and Description of Problem

PURCHASER ACKNOWLEDGEMENT

Name

Full Name (First and Last)

Purchaser Acknowledgement:
By checking this box the purchaser hereby certifies that these Trijicon products shall be used solely for the purposes described above, and not for any other purpose, and that they will not be re-exported or otherwise resold or transferred to any other country or end user without the prior written authorization from the United States Government. Diversion contrary to U.S. or International export laws is prohibited.

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International End Use Certification Statement

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