Form BIS-752P Statement by Consignee in Suppor of Special Comprehensiv

-

F

DATE RECEIVED
(Leave Blank)

U.S. DEPARTMENT OF COMMERCE

Bureau of Export Administration

FORM BIS-752P

FORMAPPROVED: OMB 0694-0089

X

STATEMENT BY CONSIGNEE IN SUPPORT OF

SPECIAL COMPREHENSIVE LICENSE

r

1. APPLICATION CONTROL NUMBER (Insert from
BXA-748P)
3. TYPE OF REQUEST
A.

0

(i.eave I:llanK)

ID

I'nfonnauon fumlshed herewith IS.lUbject to the provisions of SectIon
12(c) of the Export AdmIniatratlonAct of 1979. asamended. 50U.S.C.
app. 2411(c).and Ita unauthorized disclosure 18 prohlblled by law.

B . D CHANGE AN EXISTING CONSIGNEE

ADO A NEW CONSIGNEE

C.

0

DELETE A CONSIGNEE

,~..z: ~

4. ULTIMATE CONSIGNEE

5. SCL HOLDER

ADDRESS LINE 1

ADDRESS LINE 1

-

ADDRESS LINE 2
CITY

ADDRESS LINE 2

'POSTAL CODE
CONSIGNEE NUMBER

COUNTRY

CITY

ZIP CODE

STATE

SCL CASE NUMBER

6. DESCRIPTION OF ITEMS
We expect to use. sell, instalt, or reexport Ihe lollowing items:

-

._.
~

---_ ._-- -- -

.._..

_ ...

--.-. _ -- --.

--­

I

...._
......
.... '"'_=.... ___
....., . . . . _ _
7. CONSIGNEE'S BUSINESS AND HELATIONSHIP WITH SCL HOLDER NAMED IN BLOCK 5
.~ '

~ r=><.

_.....:..:.'.Or. .

~ ._-- ------_ . _ . _- - _

A. Nature of Business

_ -..:

-_

rt» ~ _""

~

..-.-- --_ .

~ Our relationship with the exporter
is:

1_ . .
~-:;.

-...Io ~ ~ ~

C. We have had this business
relationship for
years.

I

D. Past Sales Volume

$

I

E. ~rOjected Sales Volume

•

8. DISPOSITION OR USE OF ITEMS BY ULTIMATE CONSIGNEE NAMED IN BLOCK 4

We certify that the items:

A D Used by US (as captial equipmenl) in til e form in wilich received in the country named in Block 4 and will not be reexported or incorporated into an end product.
B. Will be processed or incorporated by us into the following product(s) for distribution in the countries authorized on the attached BXA-752-A.
C. Will be used 10 service the following commodities in the countries authorized on the attached BXA·752-A.
D. Will be resold by us in the form in which received in the country named in Block 4 for use or consumption therein. The specific end-use by my customer(s) will be:

E. D

Will be reexported by us in Ihe form in which received to countries authorized on the attached BXA-752-A.

F. Other
9. ADDITIONAL INFORMATION

..

CERTIFICATION OF CONSIGNEE
We certify that all of the facts contained in this statement are true and correct to the best of our knowledge and belief 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 SCl Holder named In Block 5, 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). We (a) will not use , reexport, sell, distribute, Install or otherwise dispose of any Items covered by this statement
contrary to U.S . Export Administration Regulations; and (b) will not sell or otherwise dispose of any of these Items to any person or firm listed on the Bureau of Export
Administration Denied Persons List or where there is reason to believe that the items will be reexported to destinations or activities not authorized by the Bureau of
Export Administration.
10. SIGNATURE OF OFFICIAL OF ULTIMATECONSIGNEE

DATE SIGNED

NAME OF OFFICIAL OF ULTIMATE CONSIGNEE

TITLE OF PERSON SIGNING THIS DOCUMENT

REQUEST AND CERTIFICATION OF SCl HOLDER
We request that the firm named in Block 4 be approved as an ultimate consignee to whom we may export items, under the Special Comprehensive License
Case Number specified in Block 5. We understand that all undertakings, commitments . obligations, and responsibilities under the special comprehensive
IicenSin? ~rocedure, and the Export Administration Regulations related thereto , are fUI~ applicable to any export to the above mentioned ultimate con­
signee i t is form is validated by the Bureau of Export Admin istration. No corrections, a dltions, or alterations were made on this form by us after the form
was signed by the official named in Block 10 above . We certify that we will not export oromerwise dispose of any items covered by the Special Compre­
hensive License to the ultimate consignee named in Block 4, until this form has been validated or after it has expired or been revoked.
SIGNATURE OF PERSON AUTHORIZED TO CERTIFY FOR SCL HOLDER
NAME OF SCL HOLDER FIRM

NAME OF PERSON SIGNING THIS DOCUMENT
ITLE OF PERSON SIGNING THIS DOCUMENT

I

DATE SIGNED

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.

X

ORIGINAL

X

F

USCOMM-OC 96-24022

.....