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pdfOMB APPROVAL NO. 1405-0003
EXPIRATION DATE: xx-xx-xxxx
*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, 2401 E St. NW, 12th Floor, Washington,
D.C. 20037.
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
Attachment?:
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Attachments Pertaining to the 22 CFR § 126.13 Certification Letter
Attachment?:
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Attachments Pertaining to the 22 CFR § 127.11 Exception to Policy Letter
Attachment?:
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Attachments Pertaining to the Basic Ordering Agreement
Attachment?:
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Attachments Pertaining to Contracts
Attachment?:
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Attachments Pertaining to the Letter of Intent
Attachment?:
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Attachments Pertaining to the Purchase Order
Attachment?:
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Attachments Pertaining to Firearms and Ammunitions Import Permits
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Attachments Pertaining to Firearms and Ammunitions Letter of Explanation
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Attachments Pertaining to Part 130 Report
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Attachments Pertaining to Product Brochures
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Attachments Pertaining to the Supplementary Explanation of Transaction
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Attachments Pertaining to Technical Data to Support Hardware License
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Attachment?:
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| File Type | application/pdf |
| File Title | H:\Documents\sample_dsp-5_v3.0.xfdl |
| Author | lunsfordtr |
| File Modified | 2015-02-27 |
| File Created | 2008-03-18 |