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pdfOMB APPROVAL NO. 1405-0092
EXPIRATION DATE: xx/xx/xxxx
*ESTIMATED BURDEN: 30 minutes
Electronic Form Version Number: 2.0
* PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 30 minutes 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, 2401 E St. NW, 12th Floor, Washington, D.C. 20037.
U.S. DEPARTMENT OF STATE
APPLICATION FOR AMENDMENT TO A DSP-5 LICENSE
*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 application. Classified information must be sent
separately to PM/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
Included Documents
Copy of DoS License with PM/DDTC Proviso(s)
DSP-6
Optional Documents
22 CFR § 126.13 Certification Letter
22 CFR § 127.11 Exception to Policy Letter
DTCC Acknowledgement Letter
Other Amplifying Data
Other DSP-6 Authorizations
Purchase order submitted with original license
DSP-6
Errors
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 considered 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.
DSP-6, Page
SEAL
1
of
6
Amendment Control No.
Signature
The Indicated License is
Amended Effective on:
The License identified in Block 4 below is amended as requested on the date
indicated at the right of this form.
UNITED STATES OF AMERICA
DEPARTMENT OF STATE
APPLICATION FOR AMENDMENT TO A DSP-5 LICENSE
*1. Date Prepared
*2. PM/DDTC Applicant/Registrant Code
02/04/2008
3. Applicant Name, Address, ZIP Code and Telephone Number
*4. Amendment to License No
I certify that the stated license has an unshipped balance and has not expired.
Subsidiary
*5. Amendment in accordance with (select one)
*Name
22 CFR § 123.25
22 CFR § 122.4
6. Compliance Case Number
*Attention
a. Provide Compliance Case Number
*Address
b. Provide date of DTCC Acknowledgement Letter (mm/dd/yyyy)
*City
*State
*ZIP Code
Ext.
*Telephone #
7. Name and Telephone Number of applicant contact(s) familiar with
the application and proposed amendments if U.S. Government needs
additional information.
Item # 1:
Name
Telephone #
Ext
Add
*8. Summary of Amendment(s) to DSP-5
9. Change Original PM/DDTC Applicant/Registrant Code (DSP-5 license, Block 2)
a. State specific reason for the change
b. PM/DDTC Applicant/Registrant Code as stated on DSP-5 license
c. New PM/DDTC Applicant/Registrant Code
10. Change Original Applicant/Subsidiary (DSP-5 license, Block 5)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Applicant/Subsidiary as stated on original DSP-5 license
d. Modified Applicant/Subsidiary
Name
Name
Attention
Attention
Address
Address
City
City
State
ZIP Code
Add
State
ZIP Code
DSP-6, Page
2
of
11. Correction to Commodity Description (DSP-5 license, Block 10)
Item # 1:
a. Type of correction (select at least one)
Change part number
Correct typographical error
b. State specific reason for the change
c. Change From - Commodity description to include the part number as
stated on original DSP-5 License
d. Corrected Commodity description to include the part number
Line Item #
Line Item #
Description
Description
Add
12. Correction to Quantity (DSP-5 license, Block 9) and/or $ Value (DSP-5 license, Block 12)
Item # 1:
a. Type of correction (select at least one)
Correct Quantity
Correct $ Value
b. State specific reason for the change
c. Change From - Quantity and/or $ Value as stated on original DSP-5 license
Line
Item #
Quantity
$ Value
Unit Price
Line Item Total
d. Change to - Quantity and/or $ Value as it should appear
Line
Item #
Unit Type
Quantity
Unit Type
Add
13. Revised DSP-5 License Total (DSP-5 License, Block 13):
a. Enter total $ value as stated on original DSP-5 license in Block 13
b. Revised total $ value
14. Correction to Foreign End-User (DSP-5 license, Block 14)
Item # 1:
a
Correct typographical error
b. Foreign End-User as stated on original DSP-5 license
c. New Foreign End-User
Name
Name
Address
Address
City
City
Add
$ Value
Unit Price
Line Item Total
6
DSP-6, Page
3
of
6
15. Change in Manufacturer of Commodity (DSP-5 license, Block 15)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Manufacturer of Commodity as stated on original DSP-5 license
d. New/Modified Manufacturer of Commodity
Name
Name
Address
Address
City
City
State
ZIP Code
State
Country
ZIP Code
Country
Add
16. Change in Source of Commodity (DSP-5 license, Block 17)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Source of Commodity as stated on original DSP-5 license
d. New/Modified Source of Commodity
Name
Name
Address
Address
City
City
State
State
ZIP Code
Country
ZIP Code
Country
Add
17. Change Name, Address and/or City of Original Foreign Consignee (DSP-5 license, Block 16)
Item # 1:
a. Type of modification (select at least one)
Change in name of original foreign consignee
b. State specific reason for the change (select at least one)
Name Change
Change in address and/or city of original foreign consignee
Location Change
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR
124 to reflect this change.
Yes
No
Not Applicable
d. Foreign Consignee as stated on original DSP-5 license
e. Modified Foreign Consignee
Name
Name
Address
Address
City
City
Country
Country
Add
DSP-6, Page
18. Change Name, Address, City, State and/or ZIP Code of Original U.S. Seller (DSP-5 license, Block 19)
Item # 1:
a. Type of modification (select at least one)
Change in name of original U.S. seller
Change in address, city, state and/or ZIP code of original U.S. seller
b. State specific reason for the change
c. U.S. Seller as stated on original DSP-5 license
d. Modified U.S. Seller
Name
Name
Address
Address
City
City
State
ZIP Code
State
ZIP Code
Add
19. Change in Foreign Intermediate Consignee (DSP-5 license, Block 18)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Foreign Intermediate Consignee as stated on original DSP-5
d. New Foreign Intermediate Consignee
Name
Name
Address
Address
City
City
Country
Country
Add
20. Change in U.S. Consignor and/or U.S. Freight Forwarder (DSP-5 license, Block 21)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. U.S. Consignor and/or U.S. Freight Forwarder as stated on original
DSP-5 license
d. New/Modified U.S. Consignor or U.S. Freight Forwarder
Name
Name
Address
Address
City
City
State
ZIP Code
Add
State
ZIP Code
4
of
6
DSP-6, Page
5
of
6
21. Additional Details of Transaction
* This application is related to a disclosure filed with Defense Trade Controls Compliance
No
Yes
Enter Compliance Disclosure Number:
*22. Applicant's Statement
,
I,
an empowered official (22 CFR § 120.25) or an official of a foreign government entity in the U.S., hereby apply for approval of the above
amendment(s); warrant the truth of all statements made herein; and acknowledge, understand and will comply with the provisions of 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 the 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 CFR § 120.27 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 license 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
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.
Signature
Signature
23. Response to be sent to: (Enter name, address and phone number:)
[Block is inactive on electronic form]
Name
Attention
Address
City
State
Telephone #
ZIP Code
Ext.
DSP-6, Page
6
of
6
CONDITIONS OF ISSUANCE
1. When approved, all of the original conditions except as modified by the Directorate of Defense Trade Controls (PM/DDTC) remain applicable.
2. This amendment, when approved, becomes a part of the license identified in Block 4 on the Page 1 of this form. When returned to the applicant, it must
be attached to the original license prior to further use of the license or must be provided to U.S. Customs and Border Protection for filing with the
original license.
DSP-6, Page
Subsidiary Information under Block 3, Page 1 of the DSP-6
*Name
*Attention
*Address
*City
*State
*Telephone #
*ZIP Code
Ext
of
6
Complete List of Amendments under Block 8, Page 1 of the DSP-6
Total Number of Amendments Selected : 0
DSP-6, Page
6
of
6
Additional Applicant/Subsidiary Changes
1
of
DSP-6, Page
1
Change Original Applicant/Subsidiary (DSP-5 license, Block 5)
10. Change Original Applicant/Subsidiary (DSP-5 license, Block 5)
Item # 2:
a. Type of modification (select one)
b. State specific reason for the change
c. Applicant/Subsidiary as stated on original DSP-5 license
d. Modified Applicant/Subsidiary
Name
Name
Attention
Attention
Address
Address
City
City
State
ZIP Code
State
ZIP Code
10. Change Original Applicant/Subsidiary (DSP-5 license, Block 5)
Item # 3:
a. Type of modification (select one)
b. State specific reason for the change
c. Applicant/Subsidiary as stated on original DSP-5 license
d. Modified Applicant/Subsidiary
Name
Name
Attention
Attention
Address
Address
City
City
State
ZIP Code
State
ZIP Code
6
of
6
Additional Contacts Information
of
DSP-6, Page
0
Additional Applicant Contact Information
Item # -18:
Item # -17:
Name
Name
Telephone #
Ext
Telephone #
Item # -16:
Item # -15:
Name
Name
Telephone #
Ext
Telephone #
Item # -14:
Item # -13:
Name
Name
Telephone #
Ext
Item # -12:
Telephone #
Item # -10:
Item # -9:
Name
Ext
Item # -8:
Telephone #
Telephone #
Item # -6:
Item # -5:
Name
Ext
Item # -4:
Telephone #
Telephone #
Item # -1:
Name
Name
Ext
Telephone #
Item # 0:
Item # 1:
Name
Name
Telephone #
Ext
Name
Ext
Item # -2:
Telephone #
Ext
Item # -3:
Name
Telephone #
Ext
Name
Ext
Name
Telephone #
Ext
Item # -7:
Name
Telephone #
Ext
Name
Ext
Name
Telephone #
Ext
Item # -11:
Name
Telephone #
Telephone #
Ext
Ext
Telephone #
Ext
Ext
Ext
of
6
Additional Commodity Description Changes
of
DSP-6, Page
0
Correction to Commodity Description (DSP-5 license, Block 10)
11. Correction to Commodity Description (DSP-5 license, Block 10)
Item # 0:
a. Type of correction (select at least one)
Change part number
Correct typographical error
b. State specific reason for the change
c. Change From - Commodity description to include the part number as
stated on original DSP-5 License
d. Corrected Commodity description to include the part number
Line Item #
Line Item #
Description
Description
11. Correction to Commodity Description (DSP-5 license, Block 10)
Item # 1:
a. Type of correction (select at least one)
Change part number
Correct typographical error
b. State specific reason for the change
c. Change From - Commodity description to include the part number as
stated on original DSP-5 License
d. Corrected Commodity description to include the part number
Line Item #
Line Item #
Description
Description
of
6
Additional Quantity and/or $ Value Changes
of
DSP-6, Page
0
of
6
Correction to Quantity (DSP-5 license, Block 9) and/or $ Value (DSP-5 license, Block 12)
12. Correction to Quantity (DSP-5 license, Block 9) and/or $ Value (DSP-5 license, Block 12)
Item # 0:
a. Type of correction (select at least one)
Correct $ Value
Correct Quantity
b. State specific reason for the change
c. Change From - Quantity and/or $ Value as stated on original DSP-5 license
Line
Item #
Quantity
$ Value
Unit Price
Line Item Total
d. Change to - Quantity and/or $ Value as it should appear
Line
Item #
Unit Type
Quantity
$ Value
Unit Price
Line Item Total
Unit Type
12. Correction to Quantity (DSP-5 license, Block 9) and/or $ Value (DSP-5 license, Block 12)
Item # 1:
a. Type of correction (select at least one)
Correct $ Value
Correct Quantity
b. State specific reason for the change
c. Change From - Quantity and/or $ Value as stated on original DSP-5 license
Line
Item #
Quantity
$ Value
Unit Price
Unit Type
Line Item Total
d. Change to - Quantity and/or $ Value as it should appear
Line
Item #
Quantity
$ Value
Unit Price
Unit Type
Line Item Total
Additional Foreign End-User Changes
of
DSP-6, Page
0
Correction to Foreign End-User (DSP-5 license, Block 14)
14. Correction to Foreign End-User (DSP-5 license, Block 14)
Item # 0:
a
Correct typographical error
b. Foreign End-User as stated on original DSP-5 license
c. New Foreign End-User
Name
Name
Address
Address
City
City
14. Correction to Foreign End-User (DSP-5 license, Block 14)
Item # 1:
a
Correct typographical error
b. Foreign End-User as stated on original DSP-5 license
c. New Foreign End-User
Name
Name
Address
Address
City
City
of
6
Additional Manufacturer of Commodity Changes
of
DSP-6, Page
0
Change in Manufacturer of Commodity (DSP-5 license, Block 15)
15. Change in Manufacturer of Commodity (DSP-5 license, Block 15)
Item # 0:
a. Type of modification (select one)
b. State specific reason for the change
c. Manufacturer of Commodity as stated on original DSP-5 license
d. New/Modified Manufacturer of Commodity
Name
Name
Address
Address
City
City
State
ZIP Code
Country
State
ZIP Code
Country
15. Change in Manufacturer of Commodity (DSP-5 license, Block 15)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Manufacturer of Commodity as stated on original DSP-5 license
d. New/Modified Manufacturer of Commodity
Name
Name
Address
Address
City
City
State
Country
ZIP Code
State
Country
ZIP Code
of
6
Additional Source of Commodity Changes
of
DSP-6, Page
0
Change in Source of Commodity (DSP-5 license, Block 17)
16. Change in Source of Commodity (DSP-5 license, Block 17)
Item # 0:
a. Type of modification (select one)
b. State specific reason for the change
c. Source of Commodity as stated on original DSP-5 license
d. New/Modified Source of Commodity
Name
Name
Address
Address
City
City
State
ZIP Code
Country
State
ZIP Code
Country
16. Change in Source of Commodity (DSP-5 license, Block 17)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Source of Commodity as stated on original DSP-5 license
d. New/Modified Source of Commodity
Name
Name
Address
Address
City
City
State
Country
ZIP Code
State
Country
ZIP Code
of
6
Additional Foreign Consignee Changes
of
DSP-6, Page
0
of
6
Change Name, Address and/or City of Original Foreign Consignee (DSP-5 license, Block 16)
17. Change Name, Address and/or City of Original Foreign Consignee (DSP-5 license, Block 16)
Item # 0:
a. Type of modification (select at least one)
Change in name of original foreign consignee
b. State specific reason for the change (select at least one)
Name Change
Change in address and/or city of original foreign consignee
Location Change
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR
124 to reflect this change.
Yes
No
Not Applicable
d. Foreign Consignee as stated on original DSP-5 license
e. Modified Foreign Consignee
Name
Name
Address
Address
City
City
Country
Country
17. Change Name, Address and/or City of Original Foreign Consignee (DSP-5 license, Block 16)
Item # 1:
a. Type of modification (select at least one)
Change in name of original foreign consignee
b. State specific reason for the change (select at least one)
Name Change
Change in address and/or city of original foreign consignee
Location Change
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR
124 to reflect this change.
Yes
No
Not Applicable
d. Foreign Consignee as stated on original DSP-5 license
e. Modified Foreign Consignee
Name
Name
Address
Address
City
City
Country
Country
Additional Seller Changes
of
DSP-6, Page
0
Change Name, Address, City, State and/or ZIP Code of Original U.S. Seller
(DSP-5 license, Block 19)
18. Change Name, Address, City, State and/or ZIP Code of Original U.S. Seller (DSP-5 license, Block 19)
Item # 0:
a. Type of modification (select at least one)
Change in name of original U.S. seller
Change in address, city, state and/or ZIP code of original U.S. seller
b. State specific reason for the change
c. U.S. Seller as stated on original DSP-5 license
d. Modified U.S. Seller
Name
Name
Address
Address
City
City
State
ZIP Code
State
ZIP Code
18. Change Name, Address, City, State and/or ZIP Code of Original U.S. Seller (DSP-5 license, Block 19)
Item # 1:
a. Type of modification (select at least one)
Change in name of original U.S. seller
Change in address, city, state and/or ZIP code of original U.S. seller
b. State specific reason for the change
c. U.S. Seller as stated on original DSP-5 license
d. Modified U.S. Seller
Name
Name
Address
Address
City
City
State
ZIP Code
State
ZIP Code
of
6
Additional Foreign Intermediate Consignee Changes
of
DSP-6, Page
0
Change in Foreign Intermediate Consignee (DSP-5 license, Block 18)
19. Change in Foreign Intermediate Consignee (DSP-5 license, Block 18)
Item # 0:
a. Type of modification (select one)
b. State specific reason for the change
c. Foreign Intermediate Consignee as stated on original DSP-5
d. New Foreign Intermediate Consignee
Name
Name
Address
Address
City
City
Country
Country
19. Change in Foreign Intermediate Consignee (DSP-5 license, Block 18)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Foreign Intermediate Consignee as stated on original DSP-5
d. New Foreign Intermediate Consignee
Name
Name
Address
Address
City
City
Country
Country
of
6
Additional U.S. Consignor and/or Freight Forwarder Changes
of
DSP-6, Page
0
of
Change in U.S. Consignor and/or U.S. Freight Forwarder (DSP-5 license, Block 21)
20. Change in U.S. Consignor and/or U.S. Freight Forwarder (DSP-5 license, Block 21)
Item # 0:
a. Type of modification (select one)
b. State specific reason for the change
c. U.S. Consignor and/or U.S. Freight Forwarder as stated on original
DSP-5 license
d. New/Modified U.S. Consignor or U.S. Freight Forwarder
Name
Name
Address
Address
City
City
State
ZIP Code
State
ZIP Code
20. Change in U.S. Consignor and/or U.S. Freight Forwarder (DSP-5 license, Block 21)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. U.S. Consignor and/or U.S. Freight Forwarder as stated on original
DSP-5 license
d. New/Modified U.S. Consignor or U.S. Freight Forwarder
Name
Name
Address
Address
City
City
State
ZIP Code
State
ZIP Code
6
Attachments pertaining to 22 CFR § 126.13 Certification Letter
Attachment?:
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Attachments pertaining to 22 CFR § 127.11 Exception to Policy Letter
Attachment?:
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Attachments pertaining to DTCC Acknowledgement Letter
Attachment?:
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Attachments Pertaining to Other Amplifying Data
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Attachments pertaining to Other DSP-6 Authorizations
Attachment?:
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Copy of DoS License with PM/DDTC Proviso(s)
Attachment?:
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Purchase order submitted with original license
Attachment?:
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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
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
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additional page was added (if you have only one continuation page).
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| File Type | application/pdf |
| File Title | H:\Documents\sample_dsp6.xfdl |
| Author | lunsfordtr |
| File Modified | 2015-02-02 |
| File Created | 2008-02-04 |