Export License Questionnaire for Bosch thermal cameras
Notice to purchaser and/or end user:	06 December 2017

The Bosch thermal camera products that you are purchasing require Bosch to collect information related to the transaction to ensure we are in compliance with United States (US) Government export control regulations. Depending on the details of the proposed transaciton, it may additionally require an export license from the US Department of Commerce.

Determination of an export license is dependent upon several factors, including, frame rate, resolution, end use, end-user, and ultimate destination.

In order for Bosch to make a determination on potential export restrictions and apply for an export license on your behalf, if necessary, all sections MUST be filled out thoroughly and completely.

Date:
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Purchaser Name and Address:
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End user Name and Address (if different):

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Please provide the names of all non-US parties who will be involved in this transaction, including their roles/responsibilities:
(Describe the flow of the transaction. Who will be the purchaser, intermediate consignee, ultimate consignee, end-user?)

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Please also provide the names of all non-US parties who will have access to the product, including their roles/responsibilities:

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End user business/industry:
☐commercial ☐military ☐both

Purchase Order/Letter of Intent/Contract Reference #:
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Product(s) to be purchased:
☐DINION IP thermal 8000 ☐MIC IP fusion 9000i

Frame rate of purchased product:
☐60 Hz ☐30 Hz ☐9 Hz

Resolution of purchased product:
☐640x480 ☐320x240

Quantity:

-If more than one camera model will be purchased, list the part number, frame rate, resolution and quantity for each model.

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Why is this quantity of the item needed by the customer?

-For example: There are 4 surveillance stations positioned around the site for 24 hour observation.

[Note: If an export license is required, this question will be asked to us by the US Government, so, we appreciate as complete a response as is possible.]

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State the purpose of this purchase, describe the end-user’s product and the business or project plans.

-For example, demonstration, evaluation, engineering/development sample, production quantity, surveillance, etc.

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If the response to question 13, above, is not the ultimate end use, please clearly describe the end use of the product:

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If this purchase is for evaluation or engineering/development of a product, please describe the product in detail, including product name, and attach any reference materials that describe the product, including brochure, data sheet, etc., if available.

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Is the camera to be embedded/integrated/installed into another product?

☐Yes	☐No

If “Yes” to question 16, above, is this product a “military commodity” (see US definition below)?

☐Yes	☐No

[Note: A “military commodity” means an article, material or supply that is described on the US Munitions List (22 CFR Part 121) or on the Wassenaar Arrangement Munitions List (WAML)). Ref. 15 CFR §744.9]

Will this product be sold to a military end-user (see below)?

☐Yes	☐No

[Note: A “military end-user” means the national armed services (army, navy, marine, air force, or coast guard), as well as the national guard and national police, government intelligence or reconnaissance organizations, or any person or entity whose actions or functions are intended to support “military end-uses” (incorporation into an item described on the USML, WAML, or a dual use item with an ECCN ending in A018 or “600” series ECCNs. Ref. 15 CFR §§744.9 & 744.17]

We (insert your Company Name) do certify that the above responses are accurate and the products which we purchase from Bosch Security Systems B.V. will be used as stated above. Additionally, in no way will these products be used for or in nuclear, chemical or biological weapons or missile technology or proliferation end applications.

Sincerely,

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Full Name	Signature

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TITLE (SOMEONE OF AUTHORITY)

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NAME OF COMPANY

ADDRESS