The following form must be completed and signed by a company officer in order to purchase any Bosch Thermal Imaging surveillance camera.

The “End-User Statement” must be completed by all customers for any Bosch Thermal Imaging surveillance camera.

If purchasing a camera model having frame rate of 25/30/50/60Hz that will be installed in any of the countries listed below, the “Consignee Statement” must also be completed and returned to Bosch. The “Consignee Statement” is not required for camera models having <9Hz frame rates, only the End User Statement.

“Consignee Statement” countries:

Argentina, Australia, Austria, Belgium, Bulgaria, Canada, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, South Korea, Spain, Sweden, Switzerland, Turkey, the United Kingdom, and the United States.

Macros must be enabled in order to complete the form. If you open this document and do not enable macros, the user fields will be disabled.

To enable macros, close the document, then reopen. When you are prompted by the Security Warning dialog box, select to enable macros.

You can access information about each field in the form by placing the cursor in the field and pressing the F1 key.

Once the form is completed, print it on paper with your company’s letterhead, sign the form, and then send it to the Bosch Security Systems Order Desk via mail, fax, or other electronic means.

ON CUSTOMER LETTERHEAD

End-User Statement

We, (End User Company Name), understand that the Bosch Thermal Imaging surveillance camera contains components that are controlled for export by the United States Department of Commerce, Bureau of Industry and Security. Sale or transfer of this camera system may require prior approval of the US Government.

We certify that the Bosch Thermal Imaging surveillance camera and/or its components will be used for (Intended Camera Purpose also include how and where it will be installed, i.e. mounted on a 20 foot pole on perimeter fence or on side of 5 story building) in (City/Country). We further certify that the use of the Cameras is strictly by a civil end user for civil end-use and will not be used or sold for use for any of the following activities:

A. Nuclear explosive activities, safeguarded and/or unsafeguarded nuclear activities including research, development, design, manufacture, construction, testing or maintenance of any nuclear explosive device or components or subsystems, nuclear reactor, critical facility, facility for the fabrication of nuclear fuel, facility for the conversion of nuclear material from one chemical form to another, facilities for the chemical processing of irradiated special nuclear or source material, facilities for the production of heavy water, facilities for the separation of isotopes of source and special nuclear material, or facilities for the fabrication of nuclear fuel containing plutonium.

B. Rocket Systems (including ballistic missile systems and space launch vehicles, sounding rockets, unmanned air vehicles including cruise missile systems, target drones and reconnaissance drones).

C. The design, development, production, stockpiling or use of chemical or biological weapons.

D. Civil End User/Use does NOT include any 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" including but not limited to Intelligence, reconnaissance, or surveillance systems suitable for supporting military operations.

The following Bosch Thermal Imaging surveillance camera will be used:

Commercial Type Number	Quantity	Purchase Order number

We understand and acknowledge that we are responsible for compliance to export regulations, including any returns for repair and/or other services.

Authorized Signature:

Print Name:

Position/Title:

Company Name:

Address:

Date:

ON CUSTOMER LETTERHEAD

Consignee Statement

As required by the U.S. Export Administration Regulations (EAR), License Exception STA – Strategic Trade Authorization, this document shall serve as our “Consignee Statement.”

We, ( (End User Company Name), acknowledge, understand and declare the following:

Is aware that Bosch Camera Assembly containing an ECCN: 6A003b.4.b thermal imaging block will be shipped pursuant to License Exception Strategic Trade Authorization (STA) in § 740.20 of the United States Export Administration Regulations (15 CFR 740.20);

Is hereby informed of the applicable ECCN number noted above.

Understands that items shipped pursuant to License Exception STA may not subsequently be re-exported pursuant to paragraphs (a) or (b) of License Exception APR (15 CFR 740.16 (a) or (b));*

Agrees not to export, re-export or transfer these items to any destination, use or user prohibited by the United States Export Administration Regulations.

Agrees to allow to be provided, or provide copies of this document and all other export, re-export or transfer records (i.e. the documents described in 15 CFR part 762) relevant to the items referenced in this statement to the U.S. Government as set forth in 15 CFR 762.7.

We understand that prior to any re-export or re-transfer of this equipment under the STA exception requires we must obtain this same “Consignee Statement” from the new consignee.

Note: The authorized export, re-export and transfer countries are:

Argentina, Australia, Austria, Belgium, Bulgaria, Canada, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Norway, Poland, Portugal, Romania, Slovakia, Slovenia,
South Korea, Spain, Sweden, Switzerland, Turkey, the United Kingdom, and the United States.

Link to the U.S. Export Administration Regulations: https://www.bis.doc.gov/index.php/regulations/export-administration-regulations-ear

Acknowledged and Certified by:

______________________________	_______________________________

Signature	Date

______________________________	_______________________________

Printed Name	Title

* Unless otherwise authorized; see Sections 734.4 “De minimis” and 750.7i “Terminating License Conditions”