DSP-5 Application/License for Permanent Export of Unclassified

Application/License for Permanent Export of Unclassified Defense Articles and Related Unclassified Technical Data

DSP-5, Form 10-2011

Application/License for Permanent Export of Unclassified Defense Articles and Related Unclassified Technical Data

OMB: 1405-0003

Document [pdf]
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OMB APPROVAL NO. 1405-0003
EXPIRATION DATE: 09-30-2008
*ESTIMATED BURDEN: 1 HOUR

Electronic Form Version Number: 3.0

* 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
APPLICATION/LICENSE FOR PERMANENT EXPORT OF UNCLASSIFIED DEFENSE
ARTICLES AND RELATED UNCLASSIFIED TECHNICAL DATA
*Transaction Number:

Please note that an Asterisk (*) next to a field in the documents designates a mandatory field.

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

To select and open a document, highlight a form and select the "Open Document" button. The document that you selected will open.
Required Documents

Included Documents
DSP-5

Optional Documents
22 CFR § 126.13 Certification Letter
22 CFR § 127.11 Exception to Policy Letter
Basic Ordering Agreement
Contract
DSP-83
Firearms and Ammunitions Import Permit
Firearms and Ammunitions Letter of Explanation
Letter of Intent
Other Amplifying Data
Part 130 Report
PM/DDTC Sec 126.8 Prior Approval
Precedent (identical/similar) Cases
Product Brochures
Purchase Order
Supplementary Explanation of Transaction
Technical Data to Support Hardware License
Technical Drawings, Schematics, or Blue Prints

DSP-5

Are you sure you want to delete this page?
To continue and delete selection, select "YES". To cancel delete, select "NO".
After the page has been deleted, you will be automatically returned to the previous continuation
page (if you have 2 or more continuation pages) or to the main page for the Block for which the
additional page was added (if you have only one continuation page).

YES

NO

U.S. DEPARTMENT OF STATE
DIRECTORATE OF DEFENSE TRADE CONTROLS
By selecting the "Submit" button, above, the Applicant hereby warrants the truthfulness of
all statements made herein and in accompanying documentation; acknowledges and understands
that, in accordance with 22 C.F.R. §127.2, it is unlawful to use any export or temporary
import control document containing a false statement or misrepresenting or omitting a
material fact for the purpose of exporting any defense article or technical data or the
furnishing of any defense service for which a license or approval is required by this
subchapter and that any false statement, misrepresentation, or omission of material fact in
an export control or temporary import control document will be consider as made in a matter
within the jurisdiction of a department or agency of the United States for the purposes of
18 U.S.C. 1001, 22 U.S.C. 2778 and 22 U.S.C. 2779; and that the applicant further agrees to
comply with all applicable provisions of 22 C.F.R. §120-130.

To cancel this submission, select "Cancel".
(If you cancel the submission, you will return to the previous page.)
Please be further advised, that if the "Submit" button is not active and you have already saved the
submission, you may not have completed all of the required fields. As a reminder you must save the
submission before you can submit.

Errors

DSP-5, Page

1

of

SEAL
Signature

DATE ISSUED

License is hereby granted to the applicant for the described commodity to be
permanently exported from the United States. This license may be revoked,
suspended or amended by the Secretary of State without prior notice whenever the
Secretary deems such action advisable.

LICENSE VALID FOR

LICENSE NO.

MONTHS FROM ABOVE DATE

UNITED STATES OF AMERICA

DEPARTMENT OF STATE

APPLICATION/LICENSE FOR PERMANENT EXPORT OF UNCLASSIFIED
DEFENSE ARTICLES AND RELATED UNCLASSIFIED TECHNICAL DATA
*1. Date Prepared * 2. PM/DDTC * 3. Country of
Ultimate Destination:
Applicant/
03/18/2008
Registrant Code

* 4. Probable Port of Exit from U.S.:

NOTE: You may only select 1 country as the ultimate destination
if the commodity(ies) being shipped include Hardware type.

5. Applicant's Name, Address, ZIP Code, Telephone Number
*Applicant is:

Government

Manufacturer

Exporter

6. Name, agency and telephone number of U.S. Government
personnel (not PM/DDTC) familiar with the commodity.
Name

Subsidiary
Telephone #

Ext.

*Name
Agency

Add

*Attention

* 7. Name and telephone numbers of applicant contact if U.S.
Government needs additional information.

*Address

*Name

*City

*Telephone #

* ZIP Code

*State
*Telephone #

Ext.

Add

Ext.

8. Description of Transaction:
*a. This application represents:

ONLY completely new shipment

ONLY the unshipped balance under license numbers

b. This application has related license numbers:
c. This application is in reference to an agreement:
*d. Commodity is being financed under:

Foreign Military Sale

Foreign Military Financing

*e. This application is related to a disclosure filed with Defense Trade Controls Compliance

Grant Aid Program
No

Not Applicable

Yes

Enter Compliance Disclosure Number:

Line *9. Quantity
Item
#
1

*10. Commodity

* 11. USML Category Number

Category

Sub

Commodity Code

Item is SME and DSP-83 is required
Unit Type

Is a DSP-83 attached?
If SME, and DSP-83 is not attached, state why.

*12. $ Value
Unit Price

Line Item Total

Defense Article Type
Add

*13. TOTAL VALUE

(Sum of All Pages) $

4

DSP-5, Page

14. Name and address of foreign end-user

2

of

15. Manufacturer of Commodity
Same as Block 5

* Name

*Name
*Address
*Address
*City
*City

*Country

State

Add

ZIP Code

*Country
Add

16. Name and address of foreign consignee

17. Source of Commodity
Same as Block 5

Same as Block 14

Same as Block 15

*Name

*Name

*Address
*Address
*City
*City

State

*Country

ZIP Code

*Country

Add

Add

18. Name and address of foreign intermediate consignee

19. Name and address of Seller in United States

None
* Name

* Name

*Address

*Address

Same as Block 5

*City

Same as Block 15

Same as Block 17

*City

*Country

*State

*ZIP Code

*Role
Add

Add

* 20. Specific purpose for which the material is required, including
specific Program/End Item.
Select at least one:

21. Name and address of consignor and/or freight forwarder in
United States

Off-Shore

Same as Block 5
Request for Prior Approval (22 CFR 126.8) * Name

Brokering (22 CFR 129)

Other (Please Provide Details)

*Address
*City
*State
Add

*ZIP Code

4

DSP-5, Page

3

of

4

DSP-5
22. Applicant's statement
I
an empowered official (ITAR 120.25) or an official of a foreign government entity in the U.S., hereby apply for a license to complete the
transaction described above; warrant the truth of all statements made herein; and acknowledge, understand and will comply with the provisions of
Title 22 CFR, 120-130, and any conditions and limitations imposed.
I am authorized 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 22 CFR 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)
a. I am authorized by the applicant to certify that the applicant and all of the parties to the transaction can meet in full the conditions of 22 CFR §
126.13 as listed above.
b. 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, as described in Section 127.11 of the ITAR,
is attached.
c. 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. However that party has met the conditions imposed by the Directorate of Defense
Trade Controls in order to resume standard submission of applications, not requiring an exception to policy as described in Section 127.11 of the
ITAR.
d. I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed above. The applicant and all of the parties to the
transaction can meet in full the conditions of 22 CFR § 126.13 as listed above. Please see the attached letter from an official that is authorized by
the applicant to certify to the conditions of 22 CFR § 126.13.
e. 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 request for an exception to policy, as described in
Section 127.11 of the ITAR, and a letter from an official that is authorized by the applicant to certify to the conditions of 22 CFR § 126.13 are
attached.
f. 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. However that party has met the conditions imposed by
the Directorate of Defense Trade Controls in order to resume standard submission of applications, not requiring an exception to policy as
described in Section 127.11 of the ITAR. Please see the attached letter from an official that is authorized by the applicant to certify to the
conditions of 22 CFR § 126.13.

*Compliance with 22 CFR 130 (Select one)
This transaction does not meet the requirements of 22 CFR 130.2
This transaction meets the requirements of 22 CFR 130.2. The applicant or its vendors have not paid, nor offered, nor agreed to pay, in respect of
any sale for which a license or approval is requested, political contributions, fees or commissions in amounts as specified in 22 CFR 130.9(a).
The applicant or its vendors have paid, or offered, or agreed to pay, in respect of any sale for which a license or approval is requested, political
contributions, fees or commissions in amounts as specified in 22 CFR 130.9(a). Information required under 22 CFR 130.10 is attached.
I am not authorized by the applicant to certify the conditions of 22 CFR 130.9(a). Please see the attached for such certification.
*Signature
Signature

23. License to be to: (Enter name, address and phone number)
[This block is inactive on electronic form.]
Same as Block 5

Hold for Pickup

Name

Address

City
State
Telephone #

ZIP Code

DSP-5, Page

4

of

CONDITIONS OF ISSUANCE
1. This license is issued under the conditions cited in 22 CFR 120 - 130, including the provisos as applicable, that:
A. It shall not be construed as implying U.S. Government approval or commitment to authorize future exports
of any article (equipment or technical data) on the Munitions List, or a U.S. Government commitment with
regard to any proposed manufacturing license or technical assistance agreements which may result from an
authorized export.
B. If a license is issued for technical data only, it does not authorize the export of any hardware; if a license is
issued for hardware only, it does not authorize the export of any technical data, unless specifically covered by
an exemption.

The issuance of this license does not release the licensee from complying with other requirements of U.S. law and regulations.

2. The prior written approval of the Department of State must be obtained before U.S. Munitions List articles
exported from the U.S. under license or other approval may be resold, diverted, transferred, transshipped,
reshipped, reexported to, or used in any country, or by any end-user, other than that described on the license
or other approval as the country of ultimate destination or the ultimate end-user.

RETURN OF LICENSE
This license must be returned to PM/DDTC, SA-1, 12th Floor, Directorate of Defense Trade Controls, Bureau of Political-Military Affairs, U.S.
Department of State, Washington, DC 20522-0112 when: (1) the total value authorized has been shipped; (2) the applicant states that there will be
no further shipments; (3) the date of expiration is reached; or (4) when requested by the Directorate of Defense Trade Controls.

ENDORSEMENT
Indicate below which ITEM on the face of the license is BEING EXPORTED and maintain a CONTINUING BALANCE of the remaining value:
SHIPMENT
DATE

QUANTITY

COMMODITY (Include classification)

SHIPMENT
VALUE

SED NO.

INITIALS

PORT OF
EXIT/ENTRY

TOTAL AUTHORIZED VALUE:

REMAINING BALANCE:

NOTE: Continuation of additional shipments must be authenticated by use of continuation sheets in the U.S.Customs handbook.

4

DSP-5, Page

Subsidiary Information under Block 5, Page 1 of the DSP-5
*Name

*Attention
*Address
*City
*State
*Telephone #

*ZIP Code
Ext

of

4

Description of Transaction

Continuation to Block 8

A. This Application represents only the unshipped balances under license

B. This Application has related license no(s)

NOTE: You must first select the appropriate check boxes under this section to add license no(s)
was licensed to the country in block 3 of the first page under license numbers.

was licensed to other countries under license numbers.

was returned without action under voided license numbers.

was denied to the country in block 3 of the first page under voided license(s)

C. This Application is in reference to agreement numbers

D. The commodities are being financed under case numbers
Foreign Military Sale

Foreign Military Financing

Grant Aid Program

DSP-5, Page

of

4

Additional Contacts Information

of

DSP-5, Page

0

Additional Applicant Contact Information

Name
Telephone #

Name
Ext

Name
Telephone #

Ext

Ext

Ext

Ext

Ext

Ext

Telephone #

Ext

Telephone #

Ext

Telephone #

Ext

Telephone #

Ext

Name
Ext

Name
Telephone #

Ext

Name

Name
Telephone #

Telephone #

Name

Name
Telephone #

Ext

Name
Ext

Name
Telephone #

Telephone #

Name

Name
Telephone #

Ext

Name

Name
Telephone #

Telephone #

Name

Name
Telephone #

Ext

Name

Name
Telephone #

Telephone #

Telephone #

Ext

Name
Ext

Telephone #

Ext

of

4

Additional Familiar Information

of

DSP-5, Page

0

Additional Contacts Familiar with Commodity Information
Name
Telephone #

Name
Ext

Telephone #

Agency

Agency

Name

Name

Telephone #

Ext

Telephone #

Agency

Agency

Name

Name

Telephone #

Ext

Telephone #

Agency

Agency

Name

Name

Telephone #

Ext

Telephone #

Agency

Agency

Name

Name

Telephone #

Ext

Telephone #

Agency

Agency

Name

Name

Telephone #

Ext

Telephone #

Agency

Agency

Name

Name

Telephone #

Ext

Telephone #

Agency

Agency

Name

Name

Telephone #
Agency

Ext

Telephone #
Agency

Ext

Ext

Ext

Ext

Ext

Ext

Ext

Ext

of

4

Additional Commodities Page #

Line 9. Quantity
Item
#
-1

of

0

10. Commodity

DSP-5, Page

Additional Commodities

of

4

11. USML Category Number

Category

Sub

Commodity Code

Item is SME and DSP-83 is required

Unit Type
Is a DSP-83 attached?
If SME, and DSP-83 is not attached, state why.

12. $ Value
Unit Price

Line Item Total

Defense Article Type
Line 9. Quantity
Item
#

10. Commodity

11. USML Category Number

Category

Commodity Code

Sub

Item is SME and DSP-83 is required

0

Unit Type

Is a DSP-83 attached?
If SME, and DSP-83 is not attached, state why.

12. $ Value
Unit Price

Line Item Total

Defense Article Type
Line 9. Quantity
Item
#

10. Commodity

11. USML Category Number

Category

Commodity Code

Sub

Item is SME and DSP-83 is required

1
Unit Type

Is a DSP-83 attached?
If SME, and DSP-83 is not attached, state why.

12. $ Value
Unit Price

Line Item Total

Defense Article Type
TOTAL VALUE

$

0

Additional Foreign End User Page #

of

0

DSP-5, Page

Additional Foreign End Users

Name

Name

Address

Address

City

City

Country

Country

Name

Name

Address

Address

City

City

Country

Country

Name

Name

Address

Address

City

City

Country

Country

Name

Name

Address

Address

City

City

Country

Country

Name

Name

Address

Address

City

City

Country

Country

Name

Name

Address

Address

City

City

Country

Country

of

4

Additional Manufacturers Page #

of

0

Manufacturer of Commodity

Name

Name

Address

Address

City

City

State

ZIP Code

State

Country

Country

Name

Name

Address

Address

City

City

State

ZIP Code

State

Country

Country

Name

Name

Address

Address

City

City

State

ZIP Code

State

Country

Country

Name

Name

Address

Address

City

City

State
Country

ZIP Code

State
Country

DSP-5, Page

ZIP Code

ZIP Code

ZIP Code

ZIP Code

of

4

Additional Foreign Consignee Page #

Name

Address

of

0

DSP-5, Page

Additional Foreign Consignees

Name

Address

City

City

Country

Country

Name

Name

Address

Address

City

City

Country

Country

Name

Name

Address

City

Address

City

Country

Country

Name

Name

Address

City

Address

City

Country

Country

Name

Name

Address

City

Address

City

Country

Country

Name

Name

Address

City
Country

Address

City
Country

of

4

Additional Sources Page #

of

0

Source of Commodity

Name

Name

Address

Address

City

City

State

ZIP Code

State

Country

Country

Name

Name

Address

Address

City

City

State

ZIP Code

State

Country

Country

Name

Name

Address

Address

City

City

State

ZIP Code

Country

State

Name

Address

Address

City

City

Country

ZIP Code

ZIP Code

ZIP Code

Country

Name

State

DSP-5, Page

ZIP Code

State
Country

ZIP Code

of

4

Additional Sellers Page #

of

0

DSP-5, Page

Additional Sellers in United States

Name

Name

Address

Address

City
State

City
ZIP Code

Name

Address

City

City
ZIP Code

Name

City
ZIP Code

Name

ZIP Code

Address

City

City
ZIP Code

Name

State

ZIP Code

Name

Address

Address

City

City
ZIP Code

Name

State

ZIP Code

Name

Address

Address

City
State

State
Name

Address

State

ZIP Code

Address

City

State

State
Name

Address

State

ZIP Code

Name

Address

State

State

City
ZIP Code

State

ZIP Code

of

4

Additional Foreign Intermediate
Consignees Page #

of

0

Additional Foreign Intermediate Consignees

Name

Name

Address

Address

City

City

Country

Country

Role

Role

Name

Name

Address

Address

City

City

Country

Country

Role

Role

Name

Name

Address

Address

City

City

Country

Country

Role

Role

Name

Name

Address

Address

City

City

Country

Country

Role

Role

DSP-5, Page

of

4

Additional Consignors Page #

of

0

DSP-5, Page

Additional Consignors in United States

Name

Name

Address

Address
City
State

City
ZIP Code

Name

Address

City

City
ZIP Code

Name

City
ZIP Code

Name

ZIP Code

Address

City

City
ZIP Code

Name

State

ZIP Code

Name

Address

Address

City

City
ZIP Code

Name

State

ZIP Code

Name

Address

Address

City
State

State
Name

Address

State

ZIP Code

Address

City

State

State
Name

Address

State

ZIP Code

Name

Address

State

State

City
ZIP Code

State

ZIP Code

of

4

Full View of Description
Item #20 of the DSP-5

DSP-5, Page

4

of

4

DSP-5, Page

Complete List of Countries under Block 3, Page 1 of the DSP-5
Total Number of Countries Selected as the Ultimate Destination:

0

4

of

4

Attachments Pertaining to the DSP-83 Form

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Attachments Pertaining to the 22 CFR § 126.13 Certification Letter

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Authorlunsfordtr
File Modified2008-03-18
File Created2008-03-18

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