BIS621-p REPORT OF REQUEST FOR RESTRICTIVE TRADE PRACTICE OR BOYC

Form BIS-621P
(REV 1-04)

OMB No.0694-0012

U.S. DEPARTMENT OF COMMERCE
BUREAU OF INDUSTRY AND SECURITY

THIS SPACE FOR BIS USE

REPORT OF REQUEST FOR RESTRICTIVE TRADE PRACTICE OR BOYCOTT
SINGLE TRANSACTION

A

(For reporting requests described in Part 769 of the Export Administration Regulations)

BATCH__

MONTH/YEAR

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NOTICE OF RIGHT TO PROTECT CERTAIN INFORMATION FROM DISCLOSURE
The Export Administration Act permits you to protect from public disclosure information regarding the quantity, description,
and value of commodities or technical data supplied in item 11 of this report and in any accompanying documents. If you do
not claim this protection, all of the information in your report and accompanying documents will be made available for public
inspection and copying.
You can obtain this protection by certifying, in item 10 of the report, that disclosure of the information referred to above would
place a United States company or individual involved in the report at a competitive disadvantage. If you make such a
certification in item 10, you may remove information regarding the quantity, description, and value of the commodities or
technical data supplied by you from item 11 of the inspection copy of the report form and from the public inspection copies of
the accompanying documents.
The withholding of this information will be honored by the Department unless the Secretary determines that disclosure of the
information would not place a United States company or individual at a competitive disadvantage or that it would be contrary
to the national interest to withhold the information.

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CLASS ___

FILING ___

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This report required by law (50 U.S.C. App. § 2407 (b)
(2) P.L. 96-72; E.O. 12214; 15 C.F.R. Part (769).
Failure to report can result both in criminal penalties,
including fines or imprisonment, and administrative
sanctions.

Instructions: 1. Complete all items that apply. 2. Assemble original report form and accompanying documents as a unit, and submit intact and unaltered. 3. Assemble and
submit the duplicate copy of the report form (marked Duplicate (Public Inspection Copy)) and additional copies of accompanying documents (marked with the legend “Public
Inspection Copy.”) 4. If you certify, in item 10, that the disclosure of the information specified there would cause competitive disadvantage, edit the ”Public Inspection Copy” of the
report form relating to item 11.
Public reporting for this collection of information is estimated to average one hour per request, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection o information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing the burden, to the Director of Administration, Bureau of Industry and Security, room 3889, U.S. Department of Commerce,
Washington, DC 20230, and to the Office of Management and Budget, Paperwork Reduction Project (0694-0012), Washington, DC 20503.

1a.

Identify firm submitting this report:

Type an ‘x’ to
specify firm type:

Name:

□ Exporter
□ Bank
□ Forwarder
□ Carrier
□ Insurer
□ Other

Address:
City

State:

ZIP:

Country (if other than USA):
Telephone:
Firm Identification No. (if known):
2.

4.

1b.

Type an ‘x’ in any applicable box:

□

Revision of a previous report (attach two copies of the
previously submitted report)

□

Resubmission of a deficient report returned by BIS
(attach form letter that was returned with deficient
report)

□
□

Report on behalf of the person identified in item 2.
Dual report on behalf of self and the person in item 2

If you are authorized to report and are reporting on behalf of another
U.S. person, identify that person (e.g., domestic subsidiary, controlled
Foreign subsidiary, exporter, beneficiary):
Name:
Address:
City:
State:
ZIP:
Country (If other than USA):
Type of firm: (see list in item 1a)
Firm Identification No. (if known):

3.

Identify exporting firm, unless same as item 1a or 2:

Name of entity from which request originated

5.

Name of country or countries against which request is directed:

7.

Date firm received request: (mm/dd/yyyy)

Name:
Address:
City:
State:
Country (If other than USA):
Firm Identification No. (if known):

ZIP:

Name of boycotting country from which request originated
6.

Reporting firm’s reference number (e.g., letter of credit, customer order,
invoice):

8.

Specify type(s) of document conveying this request by
typing an ‘x’ in the appropriate box:
Request to carrier for blacklist certificate (submit
two copies of blacklist certificate or transcript of
request)
Unwritten, not otherwise provided for (make
transcript of request and submit copies)

9.

□

□
□

□
□

□
□

Letter of credit

Requisition/purchase order/accepted contract/shipping instruction
Bid invitation/tender/proposal/trade opportunity
Questionnaire (not related to a particular dollar value transaction)
Other written (specify) _________________________________

Submit two
copies of
each
document or
relevant page
in which the
request
appears

Decision on request: (select one by typing an ‘x’ in the appropriate box)

□
□

Have not taken and will not take the action requested.
Have taken or will take the action requested.

□
□

Have taken or will take the action requested but in a modified form
(attach detailed explanation)
Unable to report ultimate decision on the request at this time and
will inform the Bureau of Industry and Security of the decision within
ten days after decision is made.

Additional information: The firm submitting this report may, if it so desires, state on a separate sheet any additional information relating to the request reported
or the response to that request. This statement will constitute a part of the report and will be made available for public inspection and copying, subject to the
right to protect certain confidential information from disclosure described in item 10.
10.
Protection of Certain Information from disclosure: (Type an ‘x’ in the appropriate boxes and sign below)
I (We) certify that disclosure to the public of the information regarding quantity, description, and value of the commodities or technical data
1.
contained in:

□

□
□
2.

□

Item 11 below (If you check this box, be sure to remove the bottom of the Duplicate (Public Inspection Copy) of the report form relating to Item 11.)
Attached documents (If you check this box, be sure to edit the “Public Inspection Copy” of the documents submitted to exclude the specified information.)
would place a United Sates person involved at a competitive disadvantage, and I (We) request that it be kept confidential.

I (We) authorize public release of all information contained in the report and in any attached documents. I (We) certify that all statements and
information contained in this report are true and correct to the best of my (our) knowledge and belief.

Sign here in ink _____________________________________
Type name ______________________________
11.
Describe the commodities or technical data involved, and specify quantity and value:
Description
Quantity:

Date ____________________

Value to nearest whole dollar $

Submit the original and 1 copy to Office of Antiboycott Compliance, BIS, Room 6099C,
U.S. Department of Commerce, Washington, D.C. 20230; Retain a copy for your records.