Statement by Ultimate Consignee and Purchaser

MKT-FRM-062 REV 1.0 BIS-711 Web Form (English) - Release Date: 06/01/14

Statement by Ultimate Consignee and Purchaser

The U.S. Department of Commerce (Bureau of Industry and Security) requires Form BIS-711 to be completed for international shipments.

Ultimate Consignee

Address

City

Postal Code

Country

Phone Number

Please check the option that best describes the use of the items purchased. We certify that the items will be:

Used by you as tools or equipment in its original form in a manufacturing process in the country named above and will not be reexported or incorporated into an end product. Processed or incorporated by you into another product and distributed. Select this option if you are an OEM. Resold by you in its original form only in the country named above for use or consumption therein. Reexported by you in its original form Other

Which product will the product be incorporated into?

What will be the specific end use?

Where will the end product be distributed to?

Where will the product be exported to?

Describe Fully, if Other

The nature of our business is

Business relationship with Amron

Years dealing with

Name of Official

Official job title

Name of Purchaser

Ultimate Destination (Country) - Country in which goods are to be consumed, further processed, stored, or manufactured

Amron's Sales Rep. or Sales Order No.

MKT-FRM-062 REV 1.0 BIS-711 Web Form (English) - Release Date: 06/01/14

Statement by Ultimate Consignee and Purchaser