Mouser Electronics, Inc.
Customer End-User Certificate for End User Name Screening

Complete the form.  Print and sign the form.  Scan and e-mail back to the person who sent you this form or Fax the form to (817) 459-5168 or e-mail to export@mouser.com. Please note that incomplete, illegible or non-specific answers will delay order shipments.

Company or Individual Information.
Name or Company Name 
     	
Address
     
	Web Address: 
     	
City
     	State
     	Country
     	Postal Code

1. Have you or has your company ever been convicted of violating U.S. Export Laws and Regulation?  If Yes, provide details below. 	  Yes           No	
2. Are you or is your company currently listed on the Denied Person List, Unverified List or Entity List of the Bureau of Industry and Security, Department of Commerce?  http://www.bis.doc.gov/ComplianceAndEnforcement/ListsToCheck.htm  	  Yes           No	
3. Are you or is your company currently listed on the Debar List of the Directorate of Defense Trade Controls, U.S. State Department?  http://www.pmddtc.state.gov/compliance/debar.html	  Yes            No	
4. Are you or is your company currently listed on the Specially Designated Nationals List of the Office of Foreign Controls, U.S. Treasury Department?  http://www.treas.gov/offices/enforcement/ofac/sdn/  	  Yes            No	

Signature of person or person authorized to sign on behalf of the company.  

Signature	Date 
     	
Printed Name 
Darth Vader	Title 

Order Information (Mouser Use Only)
Picklist or Invoice Number 
232471908	Customer Number 
5359193	Date 
01/16/15	

QS-FM-010-8	9/20/13