Export License Statement

1. Ultimate Consignee
Company Name*
City*
Address Line 1*
Country*
Address Line 2*
Postal Code*
Telephone*
2. Ultimate Consignee's Authorized Recipient (S)
Full Name*
Title*
Email Address*
Telephone*
Full Name 1
Title 1
Email Address 1
Telephone 1
Full Name 2
Title 2
Email Address 2
Telephone 2
3. Intermediate Consignee (If Applicable)
Company Name
City
Address Line 1
Country
Address Line 2
Postal Code
Telephone
4. Intermediate Consignee’s Authorized Recipient (s) (If Used)
Full Name
Title
Email Address
Telephone
Full Name 1
Title 1
Email Address 1
Telephone 1
Full Name 2
Title 2
Email Address 2
Telephone 2
5. purchaser (If Different From Ultimate Consignee)
Company Name
City
Address Line 1
Country
Address Line 2
Postal Code
Telephone
Buyer's Name
Buyer's Email Address
6. Will the product (s) be re-exported?
(If yes, please provide country of destination in 6a)*
- Yes
- No
6a. Country of ultimate destination*
7. THE FOLLOWING PRODUCTS HAVE BEEN ORDERED FROM LIST BIOLOGICAL LABORATORIES, INC.:
Product Number*
Product Name*
Quantity*
Product Number 1
Product Name 1
Quantity 1
Product Number 2
Product Name 2
Quantity 2
Product Number 3
Product Name 3
Quantity 3
Product Number 4
Product Name 4
Quantity 4
Product Number 5
Product Name 5
Quantity 5
Product Number 6
Product Name 6
Quantity 6
*Estimated # of vials requested during the 4-year period of the license.
8. Description Of Specific End-Use
8. Description Of Specific End-Use*
9. Disposition Or Use Of items By Ultimate Consignee Named In Blocks 1
We certify that the items:
1. are to be used in a laboratory by qualified personnel for research or testing purposes only and will not be used in humans;
2. will not be used for diagnostic purposes (medical or veterinary;
3. will not be used for any illegal purposes;
4. will be disposed of properly and completely when research or testing is completed
10. Statement Of Ultimate Consignee And Purchaser
We certify that all of the facts in this statement are true and correct to the best of our knowledge and we do not know of any additional facts which are inconsistent with the above statement. We shall promptly inform List Biological Laboratories, Inc. (U.S. Exporter), in writing, disclosing any change of facts or intentions set forth in this statement which occurs after the statement has been prepared and forwarded.

We will not reexport, resell, or otherwise transfer of any items approved on a license supported by this statement (1) to any country not approved for export, or (2) to any person if we know that it will result directly or indirectly, in disposition of the items contrary to the representations made in this statement or contrary to Export Administrations Regulations.
11. Ultimate Consignee Authorized Signature*
12. Purchaser Authorized signature*
Print Name & Title*
Print Name & Title*
Date (mm.dd.yy)*
MM slash DD slash YYYY
Date (mm.dd.yy)*
MM slash DD slash YYYY

Export License Statement

1. Ultimate Consignee

2. Ultimate Consignee's Authorized Recipient (S)

3. Intermediate Consignee (If Applicable)

4. Intermediate Consignee’s Authorized Recipient (s) (If Used)

5. purchaser (If Different From Ultimate Consignee)

6. Will the product (s) be re-exported?

7. THE FOLLOWING PRODUCTS HAVE BEEN ORDERED FROM LIST BIOLOGICAL LABORATORIES, INC.:

8. Description Of Specific End-Use

9. Disposition Or Use Of items By Ultimate Consignee Named In Blocks 1

10. Statement Of Ultimate Consignee And Purchaser