Collection Instrument_DS-6002_Prior Notification

Electronic Form Version Number: 0.09

OMB APPROVAL NO. ????
EXPIRATION DATE: ????
*ESTIMATED BURDEN: 1 Hour

* PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 1 hour 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: Department of State (A/RPS/DIR) Washington, D.C. 20520.

U.S. DEPARTMENT OF STATE
DIRECTORATE OF DEFENSE TRADE CONTROLS
PRIOR NOTIFICATION (22 CFR 126.8)

*Transaction Number:

Please note that an Asterisk (*) next to a field or block in a document designates a mandatory field or block.

No classified information can be included in this request. Classified information must be sent
separately to DDTC in accordance with the Defense Security Service guidelines.
Classified information is being sent under separate cover

To open a document, click on a document to highlight it and select the "Open Document" button. The document that
you selected will open.
Required Documents
DS-6002
Descriptive Literature

Included Documents

Open Document
Optional Documents
126.13 Eligibility Letter
Transaction Exception Request
Open Document

Open Document

DS-6002
MM-YYYY Revised

DS-6002, Page

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DATE RECEIVED: 04/12/2005
CASE NO.

UNITED STATES OF AMERICA

DEPARTMENT OF STATE

PRIOR NOTIFICATION (22 CFR 126.8)
*1. Date Prepared 04/12/2005

*2. DDTC Applicant/Registrant Code

3. Applicant Name, Address, ZIP Code and Tel. No.

4. Names, agency and telephone numbers of U.S. Government
personnel (not DDTC) familiar with the request

Subsidiary

Name
*Name

Agency

Agency

Specify Other
Ext

Telephone #

*Attention

Add More Government Contacts

*Addres

5. Name and telephone number of applicant contact(s)
*City
*State

State

Name

*ZIP Code

Telephone #
*Telephone #

Ext

Ext
Add More Applicant Contacts

*6. Country(s) of Ultimate Destination
*7. Specific purpose for which defense articles will be used

Country

<==

View
Full
List

*8. Name of foreign end-user(s)
Name

Address
City
Country

Country

Add More Foreign End Users

Line
*9. Commodity
Item #

Full View of Description

Category

1

*11. Previous Case Number
(Provide at least one)

*10. USML Category

Sub

FMS LOA Number

Commodity Code
DDTC Approval Number

Add More Items

*12. Value of Proposed Transaction

*13. Is the purpose of the proposal/presentation for the manufacture
abroad of Significant Military Equipment (SME)?
Yes

No

1

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CASE NO.
14. Additional Details of Transaction

View Full Description

* 15. Applicant's statement
, an empowered official (ITAR 120.25) hereby submit a prior notification; warrant the truth of all statements made

I,

herein; and acknowledge, understand and will comply with the provisions of Title 22 CFR 120-130, and any conditions and limitations imposed.
I am a responsible official empowered by the applicant to certify the following in compliance with 22 CFR 126.13:
(1) Neither applicant, its chief executive officer, president, vice presidents, other senior officers or officials (e.g., comptroller, treasurer, general counsel)
nor any member of its board of directors is:
(a) the subject of an indictment for or has been convicted of violating any of the U.S. criminal statutes enumerated in 22 CFR120.27 since the
effective date of the Arms Export Control Act, Public Law 94-329, 90 Stat. 729 (June 30, 1976); or
(b) ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an export
license or other approval from any agency of the U.S. Government;
(2) To the best of the applicant's knowledge, no party to the export as defined in Section 126.7 (e) has been convicted of violating any of the U.S.
criminal statutes enumerated in 22 CFR 120.27 since the effective date of the Arms Export Control Act, Public Law 94-329, 90 Stat. 729 (June 30, 1976);
or is ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an export lisence
or other approval from any agency of the U.S. Government.

22 CFR 126.13 Certification (Select one)
I am authorized by the applicant to certify that the applicant and all the parties to the transaction can meet in full the conditions of 22 CFR 126.13
as listed above.
I am authorized by the applicant to certify to 22 CFR 126.13. The applicant or one of the parties of the transaction cannot meet one or more of
the conditions of 22 CFR 126.13 as listed above. A request for an exception to policy is attached.
I am not authorized by the applicant to certify the conditions of 22 CFR 126.13 as listed above. The applicant and all the parties to the transaction
can meet in full the conditions of 22 CFR 126.13 as listed above. Please see the attached letter for such certification.
I am not authorized by the applicant to certify the conditions of 22 CFR 126.13 as listed above. The applicant or one of the parties of the
transaction cannot meet one or more of the conditions of 22 CFR 126.13 as listed above. A letter of such certification and request for an
exception to policy is attached.
Signature

Signature

16. Response to be sent to (Enter name, address and tel. no.)

[Block is inactive on electronic form.]
Same as Block 4

Hold for Pickup

Name
Attention
Address
City
State
Telephone #

State

ZIP Code
Ext

DS-6002, Page

Subsidary Information under Block 4, Page one of DS-6002
Name

Attention
Address
City
State
Telephone #

State

ZIP Code
Ext

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