IV TECH GA, 2356 Standing Peachtree Ct NW, Kennesaw, GA 30152. T: 678-460-7009
1.
2.
3.
4.
5.
Enter the end-user name and address. Make sure the address is complete, and includes a city and
country. If the customer is different than the end-user, also provide its complete address information.
Note that the term “missiles” is construed very broadly, and includes all types of “unmanned air vehicles.”
Mark all of the listed activities or industries that apply to the end-user (and customer), where requested.
Nuclear-related activities include nuclear facilities, nuclear explosives or weapons activities, manufacturing
of parts used in atomic facilities, nuclear or atomic reprocessing plants, nuclear or atomic waste activities,
nuclear or atomic “source” material, separation of isotopes of any source or special nuclear material,
production of heavy water, nuclear fuel fabrication, plants of any kind supported by fast breeder reactors,
radiological facilities, and uranium facilities.
Military entities include, but are not limited to, armed forces, ministries of defense, and intelligence
organizations. Military end uses include, but are not limited to, command, control and intelligence
applications.
The Screen Checklist may be completed electronically in MS Word. To use the Checkboxes, “double click” on
desired response box, select the “Checked” dial, and click the “OK” button to close the screen.
Important: read the instructions and questions carefully before completing.
End-User
Address (PO Boxes unacceptable)
Address line 2
City
State/Province
Postal
Country
Available Website(s):
(Complete if the Customer is not the same as the End-User, if not indicate “SAME”):
Customer Number(s)
Customer
Address (PO Boxes unacceptable)
Address line 2
City
State/Province
Available Website(s):
Postal
Country
1.1. Will our product or service ultimately be shipped to or utilized in Iraq or Libya?
1.1.1.
2.
YES
NO
If YES: Reminder- the IRAQ / LIBYA CHECKLIST FORM DIEC 18-0100-011 must also be completed for
each transaction when they occur.
PROLIFERATION END-USER / END-USES SCREENING
5.1. Is the end-user, and if different the customer, directly or indirectly involved in the design, production, or use of
missiles, including rockets, unmanned air vehicles, space launch vehicles, sounding tracks, target drones, remotely
piloted vehicles, or reconnaissance drones? END-USER - YES
NO
CUSTOMER - YES
NO
5.2 Is the end-user, and if different the customer, involved in any of the following industries or activities? (Check all
that apply)
END-USER - YES
NO
CUSTOMER - YES
NO
Power plants
Energy plants
Nuclear facilities
Radiological facilities
Chemical plants
Pharmaceuticals
Semiconductor manufacture
Mining operations
Petrochemical plants
Metal manufacture
Paper manufacture
Chemical weapons
Petroleum
Organic synthesis
Paint manufacture
Biological agents
Biological weapons
Cosmetics
Insecticides/pesticides
Food Processing Equip.
Plastic/rubber mfg.
Textile dyes
Glass/ceramic porcelain mfg.
Armaments
DIEC 18-0100-001 – Export EPCI Proliferation Screening Form
Record Retention – 5 years from date of expiration
Page 1 of 2
Rev 4.0 041008
5.3 Is the end-user, and if different the customer, a government or government-owned entity?
END-USER - YES
NO
CUSTOMER - YES
NO
5.4 Is the end-user, and if different the customer, a military entity or will Dresser product ultimately be for military use?
END-USER - YES
NO
CUSTOMER - YES
NO
5.5 Is the end-user, and if different the customer, directly or indirectly involved in any nuclear-related activity?
END-USER - YES
NO
CUSTOMER - YES
NO
5.6 Is the end-user, or if different the customer, a Nuclear Facility or Plant?
END-USER - YES
NO
CUSTOMER - YES
NO
5.6.1 If YES, will our product be used or likely used in the Containment - Reactor Area? YES
7.
NO
INTENDED END-USE
7.1. Please describe briefly the intended end-use(s) of the Dresser product(s) by the End-User including the
industry application (be sure to explain all activities in Q5.2, if indicated):
8.
ELECTRONIC SIGNATURE
To maintain this form via any electronic means, you are agreeing that your typed name may be used as
equivalent to your original signature and confirm the same.
DRU or Channel Partner Name:
Legibly Print your name and Sign
(Or Typed Name above indicates Electronic Signature)
Date
INSTRUCTIONS
THANK YOU FOR YOUR DUE DILIGENCE IN COMPLETING THIS IMPORTANT
EXPORT
DIEC 18-0100-001 – Export EPCI Proliferation Screening Form
Record Retention – 5 years from date of expiration
Page 2 of 2
Rev 4.0 041008