Letterhead of the end-user/consignee in the country of final destination
End-Use Certificate for Dual-Use Items (EU Reg. 428/2009)
(if issued by the government authority, a unique identifying Certificate number N° ...)
A. Parties
1. Exporter
5. Please describe the
route the items will take:
Name:
Company Registration Number:
Website:
Registered Address:
Contact Person + Tel. + E-mail:
6. Country of Final End
Use:
2. Consignee
Name:
Company Registration Number:
Website:
Registered Address (no PO Box):
If different; shipping address:
Contact Person + Tel. + E-mail:
3. End-User (if different from Consignee)
Name:
Company Registration Number:
Website:
Registered Address (no PO Box):
If different; shipping address:
Contact Person + Tel. + E-mail:
4. Other involved entities (agent, broker, transporter, reseller, etc…)
(please indicate name, full address, and contact details)
Please sign every page
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Letterhead of the end-user/consignee in the country of final destination
B. Items
1. Items
(Product name / description)
2. Quantity (Units) /
Weight
3. Order / Invoice / Contract number
4. Nature of the End Use

Civil

Governmental

Defence-related

Other
5. End-Use Description
(Please give a clear description; if the end use is integration, testing, research or similar, please indicate the
nature of the end use and end users of the product you are producing / testing / researching / …)
6. Specification of the end-use location of the items
(Please indicate in this section the location where the items will be used. For example at which branch or by
what sub-division the items will be used.)
7. (Optional) Any Additional Relevant Information
Please sign every page
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Letterhead of the end-user/consignee in the country of final destination
C. Declaration of foreign end user (or reselling consignee)
Context:
Art. 9.2. of the EU Regulation EC 428/2009 states that the granting of an export licence may be subject to an obligation to
provide an end-use certificate. The competent export control authority Strategic Goods Control Unit, Flemish Department of
Foreign Affairs, Havenlaan 88 bus 80, 1000 BRUSSEL, Belgium, requires a correctly filled-out and signed end use certificate for
every individual export licence application.
Signing this end-use certificate contractually binds the signing company to the receiving government. Violation of the
declarations made hereunder may result in contractual penalties, and administrative and/or diplomatic measures.
Declaration:
C.1. Please tick this box to indicate that your company will act as end user and fully
obligates itself to the following (for traders, whole- or re-sellers see section C.2. below)
We (I) certify that the items described in Section B. supplied by the exporter named in Section A.1.:
1.
2.
3.
4.
5.
6.
will only be used for the purposes described in Section B.5. and that the items or any replica thereof are intended for final
use in the country named in Section A.6.;
that the items or any replica thereof will not be used in any nuclear explosive activity or unsafeguarded nuclear fuel-cycle
activity;
that the items will not be used for any purpose connected with chemical or biological or nuclear weapons, or missiles or
UAVs capable of delivering such weapons;
that the items will only be used for civil end-uses (delete if not applicable);
as far as technology is concerned, we (I) certify) that we (I) treat the technology strictly confidential and neither pass the
technology on to other companies nor shall we (I) make knowledge available to third parties. In case of goods produced by
the help of transferred technology, these goods will only be delivered to a third person/company on condition that this third
person/company accepts the commitments of the above declaration as binding for itself and on condition that this third
person/company is known to be trustworthy and reliable in the observance of such commitments.
We (I) further certify that we (I) will not re-export the items to third countries without the consent of the Belgian authorities.
Re-exportations to EU countries or Countries listed in Annex IIa of EU dual-use Reg. n° 428/2009 (Australia, Canada,
Japan, New Zealand, Norway, Switzerland, including Liechtenstein, and United States of America) do not require any
consent of the Belgian authorities.
C.2. Please tick this box to indicate that your company will act as trader, whole- or reseller (only to be completed if Section C.1. is not applicable / end-user cannot be determined yet)
We (I) certify that the items described in Section B. supplied by the exporter named in Section A.1. will only be delivered to
customers considered absolutely reliable by this company.
1.
2.
3.
The customers shall declare unequivocally that the items described in Section B. or any replica thereof will not be used in
any nuclear explosive activity or unsafeguarded nuclear fuel-cycle activity; that the items will not be used for any purpose
connected with chemical or biological or nuclear weapons, or missiles or UAVs capable of delivering such weapons.
The goods will only be delivered to a third person/company on condition that this third person/company accepts the
commitments of the above declaration as binding for itself and on condition that this third person/company is known to be
trustworthy and reliable in the observance of such commitments.
The customer shall not re-export the goods to third countries without the consent of the Belgian authorities. Reexportations to EU countries or Countries listed in Annex IIa of EU dual-use Reg. n° 428/2009 (Australia, Canada, Japan,
New Zealand, Norway, Switzerland, including Liechtenstein, and United States of America) do not require any consent of
the Belgian authorities.
Signature:
___________________________________
Place, Date
___________________________________
Official signature of end-user
___________________________________
Company Stamp / Official Seal
___________________________________
Name and title of signer in block letters (and
transcription in Latin Alphabet if relevant)
Certification of signature:
End user can request certification of this document by Belgian embassy or via local Chamber of Commerce Stamp.
Any end use certificate not certified in advance may be certified during the licence procedure. The signer may be
contacted by the Belgian embassy or the Flemish economic representation.
Please sign every page
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