Form BIS-645P Internataional Import Certificate

General Instructions
The International Import Certificate, BIS-645P form is available on the BIS Web site. BIS
requires only one signed copy to be submitted via mail. Once the IIC is signed with the authorized
signature, the original and a copy(s) will be returned to you.
The IIC=s, BIS-645P form should be mailed to the following address.
Via Courier or Regular mail:
Bureau of Industry and Security
U.S. Department of Commerce
14th Street and Pennsylvania Avenue, N.W.
Room 2705
Washington, D.C. 20230
Attn: AIIC enclosed@

Please disregard the P.O. Box address for
the Department of Commerce listed on
the back of the IIC Form.

Form Approved: OMB No. 0694-0017- Modele approuve: OMB No. 0694-0017

FORM BIS-645P/ATF-4522/DPS-53 (REV 8/02)

u.s. DEPARTMENT OF COMMERCE
Bureau of Industry and Security
U.S. DEPARTMENT OF THE TREASURY
Bureau of Alcohol, Tobacco and Firearms
U.S. DEPARTMENT OF STATE
Office of Munitions Control

INTERNATIONAL IMPORT CERTIFICATE
(CERTIFICAT INTERNATIONAL D'IMPORTATION)

NOTE:

Read instructions on the reverse side before completing and
submitting this form. (Lire les instructions au verso avant de
remplir et de presenter la presente formule.)
1. U.S. ImporterlImportateur (Name and address-Nom et adresse)

Certificate Number

2. ExporterlExportateur (Name and address-Nom et adresse)

If this form has been approved by the Department of Commerce or the Department of State, it is not valid unless the official seal of the Department of
Commerce, or the Department of State, appears in this space. If this form is
approved by the Treasury Department, a seal is not required. (Si ce formulaire
a ete approuve par le Ministere du Commerce, ou le Ministere des Affaires
Etrangeres, il n'est pas valide it moins qu'un sceau officiel du Ministere du
Commerce ou du Ministere des Affaires Etrangeres soit appose sur le document. Si ce formulaire est approuve par le Ministere des Finances, un sceau
officiel n'est pas necessaire,

FOR U.S. GOVERNMENTUSE (Reserve pour Ie Gouvemment des EtatsUnis)

3.

TSUS Anno. No.
(Numero de la
liste)

Description of goods
(Designation de la Marchandise)

Quantity
(Quantib~)

Value
(Valeur)
(FOB, CI~ etc.)

4. Representation and undertaking of U.S. importer or principal

The undersigned hereby represents that he has undertaken to import into the United States of America under a U.S. Consumption Entry or U.S. Warehouse Entry
the commodities in quantities described above, or, if the commodities are not so imported into the United States of America, that he will not divert, transship, or
reexport them to another destination except with explicit approval of the Department of Commerce, the Department of State, or the Department of the Treasury,
as appropriate. The undersigned also undertakes to notify the appropriate Department immediately of any changes of fact or intention set forth herein. If a
delivery verification is required, the undersigned also undertakes to obtain such vertification and make disposition of it in accordance with such requirement.
Any false statement willfully made in this declaration is punishable by fine and imprisonment. (See experts from U.S. Code on reverse side.)
Declaration et engagement de l'importateur ou du commettant des Etats-Unis

Le soussigne declare par la presente qu'il a pris l'engagement d'importer aux Etats-Unis d'Amerique, en vertu d'une Declaration americaine de Mise en Consommation,
ou d'une Declaration americaine d'Entree en entrepot, la quantite de produits ci-dessus et que, dans le cas ou ces produits ne seraient pas ainsi importes aux
Etats-Unis d'Amerique, il ne le detournera, ne les transbordera, ni les reexportera a destination d'un autre lieu, si ce n'est avec l'approbation explicite du Ministere
du Commerce, du Ministere des Affaires Etrangeres ou du Ministere des Finances, comme il est requis. Le soussigne prend egalement l'engagement d'aviser Ie
Ministere interesse des Etats-Unis de tous changements survenus dans les actes ou les intentions enonces dans la presente declaration. Si demande est faite d'une
confirmation de la livraison le soussigne prend egalement l'engagement d'obtenir cette continuation et d'en disposer de la maniere prescrite par cette demande.
Toute fausee declaration faite intentionnellement espose 1'auteur aux penalites prevues par la loi. (Voir Extrait du Code des Etats-Unis au verso.)
Type or Print
(Priere d'ecrire
a la machine ou
en caracteres
d imprimerie)

Type or Print
(Priere d' ecrire
a la machine ou
en caracteres
d imprimerie)
Name of Finn or Corporation
(Nom de la Finne ou de la Societe)

Narne and TItle of Authorized Official
(Nom et titre de l'agent ou employe autorise)

Signature of Authorized Official
(Signature de l'agent ou employe autorise)

Date of Signature
(Date de la signature)

This document ceases to be valid unless presented to the competent foreign authorities within six months from its date of issue. (Le present document perd sa
validite s'il n'est pas remis aux auto rites etrangeres competentes dans un delai de six mois it compter de sa delivrance.)
No import certification may be obtained unless this International Import Certificate has been completed and filed with the appropriate U.S. Government agency
(Department of Commerce: 50 U.S.C. app. §2411, E.O. 1221415 C.ER. §368; Department of the Treasury; 22 U.S.C. §2778, E.O. 11959,27 C.ER. §47; Department of
State: 22 U.S.C. 2778, 2779, E.O. 11958,22 C.ER. §123). Information furnished herewith is subject to the provisions of Section 12(c) of the Export Administration Act
of 1979,50 U.S.C. app. 2411(c), and its unauthorized disclosure is prohibited by law.
FOR U.S. GOVERNMENT USE (Reserve au Gouvernement des Etats-Unis)
Certification: This is to certify that the above declaration was made to the U.S.
Department of Commerce, State, or Treasury through the undersigned designated official thereof and a copy of this certification is placed in the official files.

Certification: nest certifie par la presente que la declaration ci-dessus a ete
faite au Ministere du Conunerce, des Affaires Etrangeres, ou des Finances des
Etats-Unis par l'intermediaire du fonctionnaire autorise sousssigne de ce Ministere
et qu'une copie de ce certificat a ete conservee dans les archives officielles.

Signature

Date

Designated Commerce, State, or Treasury Official (Fonctionnaire competent du Ministere du Commerce, d'Etat, ou du Tresor)

_

Date
USCOMM DC 89·24414

ORtGtNAL COpy