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pdfSTATEMENT OF REGISTRATION INSTRUCTIONS
General Notes:
- Complete all items. If “none” applies to an item, so state.
- If more space is required to complete an item, electronic attachment pages are available for most items.
- Important: Changes in the information contained in this application by law must be reported promptly in accordance with 22 CFR
122.4. Clearly identifying or otherwise highlighting the changed information will facilitate analysis.
Block 1. Show the legal business name, physical office address, and telephone number of the registrant. No P.O. Box address accepted.
Block 2. If you have been, or are currently, registered with the Directorate of Defense Trade Controls (PM/DDTC), give your PM/DDTC registrant
code number.
Block 3. For DDTC use only and should be left blank. Registrants will be advised of the fee schedule on the DDTC website. For renewals,
registrants will be notified of their annual fee via mail 60 days prior to expiration date. Payment must be submitted by check or money order and
must be in U.S. currency, payable through a U.S. financial institution. Cash and foreign currency will not be accepted. Make check or money order
payable to “U.S. Department of State.” Send to one of the addresses provided below.
Block 4. Give the most applicable legal organizational description. If "other" is selected, explain legal organizational structure. Select one.
Block 5. Indicate the nature of your business as a Manufacturer, Manufacturer/Exporter, or Broker of Defense Articles and Services (e.g.,
hardware, data, software, services) and select only one. Separate registration required for Broker. Manufacturer or Manufacturer/Exporter must
be a U.S. person. Broker may be a U.S. person or a foreign person and the appropriate entry marked in Block 5.
Block 6. Enter the date (mm-dd-yyyy), city, county, state, and country where your legal business, as listed in Item 1, commenced doing business.
You must attach a copy of the document(s) issued by the government authority enabling you to engage in business in the U.S. (e.g. Articles of
Incorporation) or foreign country, as appropriate.
Block 7. Enter the full name, title, date (mm-dd-yyyy), place of birth (city, state, & country), social security number, complete physical home
address, and country of citizenship (list all citizenships held, actual or pending, including whether or not you are a U.S. person under 22 CFR
120.15). No P.O. Box address accepted.
Block 8. Enter U.S. Munitions List (USML) category (22 CFR 121), generic name, in addition the U.S. Government agency (if applicable) for
USML articles manufactured, and/or exported, brokered, or defense services provided.
Block 9. List U.S. defense-related subsidiaries/affiliates, wholly or partially owned by registrant for USML articles manufactured, and/or exported,
or defense services provided. Telephone number is not mandatory but could facilitate analysis.
Block 10. List defense-related foreign subsidiaries/affiliates, wholly or partially owned by registrant for USML articles manufactured, and/or
exported, or defense services provided. Telephone number is not mandatory but could facilitate analysis.
Block 11. Give complete name, address, and telephone number of parent company.
Block 12. Is the registrant owned and/or controlled by foreign (non U.S.) person(s)? See 22 CFR 122.2 (c) for definition of ownership or control. If
“Yes,” you must explain in the transmittal letter the specific percentages of ownership and control held by each foreign (non U.S.) person.
Block 13. Company entities or subsidiaries may not register separately.
Block 14. The individual signing this form must be a senior officer empowered by the registrant. The signer must be a U.S. person unless the
signer is a broker, which includes U.S. and non-U.S. persons. Violations and penalties are explained in 22 CFR 127.
Send to:
Postal Mailing Address
U.S. Department of State
Directorate of Defense Trade Controls
Compliance and Registration Division
2401 E Street, NW, SA-1, Room H1200
Washington, DC 20522-0112
Send to:
Express Mailing Address and Courier Delivery Address
U.S. Department of State
Directorate of Defense Trade Controls
Compliance and Registration Division
2401 E Street, NW, SA-1, Room H1200
Washington, DC 20037
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
AUTHORITIES U.S. Department of State’s authorities to register persons engaged in the business of manufacturing, exporting, or importing any defense article
or defense service are 22 USC 2778 (b) (1) (A) (i) and 22 CFR Part 122. The authorities to register brokers are 22 USC 2778 (b) (1) (A) (ii) (I) and 22
CFR 129.3 and 129.4.
PURPOSE The purpose of registration is to provide the U.S. Government with necessary information on individuals and entities engaged in certain
manufacturing, exporting, and brokering activities.
ROUTINE USES The information solicited on this form is made available as a routine use to appropriate agencies whether Federal, State, local or foreign, for
intelligence, law enforcement, and administrative purposes, or pursuant to a court order. It may also be used to send required reports to Congress about certain
defense trade transactions.
SOCIAL SECURITY NUMBER Disclosure of the social security number(s) is voluntary and for the purpose of facilitating coordination with the Department of
Treasury to review the registration statement for law enforcement concerns in accordance with 22 USC 2778 (b) (1) (B). Refusal to provide requested social
security number, by itself, will not result in registration being denied, but may result in delays in the processing of a registration request.
*Public reporting burden for this collection of information is estimated to average 2 hours per response, including time required for searching existing data
sources, gathering the necessary data, providing the information required, and reviewing the final collection. Send comments on the accuracy of this estimate of
the burden and recommendations for reducing it to: U.S. Department of State (A/ISS/DIR) Washington, DC 20520.
DS-2032
06-2008
Instruction Page 1 of 1
OMB APPROVAL NO 1405-0002
EXPIRATION DATE 09/30/2008
*ESTIMATED BURDEN 2
U.S. Department of State
Hours
STATEMENT OF REGISTRATION
PM/DDTC Date Received (mm-dd-yyyy)
(SEE INSTRUCTIONS PAGE)
(Attach additional sheet if necessary)
1. Registrant’s Name and Address
New Registrant Code
2. Current Registration Code (if applicable)
Manufacturer
Broker
a. Name
3. For DDTC Use Only
b. Doing Business As
$
Enclosed (for 12 month registration)
4. Registrant Is:
c. Physical Street Address
Individual
Corporation
5. Registrant Is:
Manufacturer
d. Apt. (no P.O. Box)
Partnership
Other
Company
Manufacturer/Exporter
US Person
e. City
Broker
Foreign Person
f. State/Province
g. Country
6. Incorporation or Commencement of Business:
Date (mm-dd-yyyy)
h. Zip/Postal Code
Telephone Number (Country/Area Code)
In
Fax Number (Country/Area Code)
City, County, State, and Country
7. Directors, Officers, Partners, Owners:
Name
Date of Birth (mm-dd-yyyy)
a. Last
Place of Birth
Home Address
a. Physical Street Address
a. City
b. First
b. State/Province
c. Middle
d. Citizenship(s)
e. Social Security Number
b. Apt. (no P.O. Box)
c. City
c. Country
d. State/Province
e. Country
f. Zip/Postal Code
f. Position
Additional page(s) attached
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06-2008
Page 1 of 2
8. U.S. Munitions List Articles Manufactured and/or Exported, Brokered, or Defense Services Provided:
Purchasing U.S.
Government
Category
Commodity/Service
Agency (If Any)
Additional page(s) attached
9. Names and Addresses of Registrant’s Wholly- and
Partially-Owned U.S. Subsidiaries/Affiliates:
Yes (Specify)
No
10. Names and Addresses of Registrant’s Wholly- and
Partially-Owned Foreign Subsidiaries:
Yes (Specify)
No
a. Name
a. Name
b. Physical Street Address (no P.O. Box)
b. Physical Street Address (no P.O. Box)
c. City
c. City
d. State/Province
d. State/Province
e. Zip/Postal Code
e. Country
f. Telephone Number (Country/Area Code)
f. Zip/Postal Code
g. Telephone Number (Country/Area Code)
Additional page(s) attached
11. Name, Address, and Telephone Number of
Registrant’s Parent Company (if any)
Additional page(s) attached
12. Is The Registrant
Owned
And/Or Controlled
By Foreign Persons (22 CFR 122.2 (c)):
a. Name
b. Physical Street Address (no P.O. Box)
Yes (Specify)
No
13. Does Registrant Submit Federal Income Tax Forms
Separately From Company in Block 11?
c. City
Yes
No
d. State/Province
e. Country
f. Zip/Postal Code
g. Telephone Number (Country/Area Code)
Additional page(s) attached
14. Registrant’s Statement:
Under Penalty According to Federal Law (see 22 CFR 127; 22 USC 2778, 18 USC 1001)
I,
Warrant The Truth of All Statements Made Herein
Type Full Name
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06-2008
Signature
Date (mm-dd-yyyy)
Title/Position of Senior Officer
Email
(DESTROY PREVIOUS EDITIONS)
Page 2 of 2
Additional Directors, Officers, Partners, Owners
Block 7
Name
Date of Birth (mm-dd-yyyy)
a. Last
Place of Birth
b. First
a. City
c. Middle
b. State/Province
d. Country of Citizenship(s)
Home Address
a. Physical Street Address
b. Apt. (no P.O. Box)
c. Country
c.
City
e. Social Security Number
d. State/Province
f. Position
e. Country
f. Zip/Postal Code
Name
Date of Birth (mm-dd-yyyy)
a. Last
Place of Birth
b. First
a. City
c. Middle
b. State/Province
d. Country of Citizenship(s)
Home Address
a. Physical Street Address
b. Apt. (no P.O. Box)
c. Country
c. City
e. Social Security Number
d. State/Province
f. Position
e. Country
f. Zip/Postal Code
Name
Date of Birth (mm-dd-yyyy)
a. Last
Place of Birth
b. First
a. City
c. Middle
b. State/Province
d. Country of Citizenship(s)
Home Address
a. Physical Street Address
b. Apt. (no P.O. Box)
c. Country
c. City
e. Social Security Number
d. State/Province
f. Position
e. Country
f. Zip/Postal Code
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Additional U.S. Munitions List Articles Manufactured and/or Exported, Brokered, or
Defense Services Provided
Block 8
Category
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06-2008
Commodity/Service
Purchasing U.S.
Government
Agency (If Any)
Additional Names and Addresses of Registrant’s Wholly- and Partially-Owned U.S. Subsidiaries
Block 9
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Zip/Postal Code
f. Telephone Number (Country/Area Code)
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Zip/Postal Code
f. Telephone Number (Country/Area Code)
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Zip/Postal Code
f. Telephone Number (Country/Area Code)
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Zip/Postal Code
f. Telephone Number (Country/Area Code)
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Additional Names and Addresses of Registrant’s
Wholly- and Partially-Owned Foreign Subsidiaries
Block 10
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Country
f. Zip/Postal Code
g. Telephone Number (Country/Area Code)
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Country
f. Zip/Postal Code
g. Telephone Number (Country/Area Code)
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Country
f. Zip/Postal Code
g. Telephone Number (Country/Area Code)
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Country
f. Zip/Postal Code
g. Telephone Number (Country/Area Code)
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Additional Name, Address, and Telephone Number of Registrant’s Parent Company
Block 11
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Country
f. Zip/Postal Code
g. Telephone Number (Country/Area Code)
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Country
f. Zip/Postal Code
g. Telephone Number (Country/Area Code)
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Country
f. Zip/Postal Code
g. Telephone Number (Country/Area Code)
a. Name
b. Physical Street Address (no P.O. Box)
c. City
d. State/Province
e. Country
f. Zip/Postal Code
g. Telephone Number (Country/Area Code)
DS-2032
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File Type | application/pdf |
File Title | Microsoft Word - Statement of Registration - Updated - 8.08.08.doc |
Author | carltonmj |
File Modified | 2008-08-08 |
File Created | 2008-08-08 |