This Form is designed by meti and shall be completed by the end-user in the country of destination

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(This Form is designed by METI and shall be completed by the end-user in the country of destination.)

(Name of the exporter in Japan)


for presentation to the Export Control Authority of Japan (METI)


(a) Name of Exporter

(b) Name of Buyer

(c) Buyer’s Address

(d) Name of Consignee

(e) Consignee’s Address

(f) Name of End-User

(g) End-User’s Address

(h) Specific Location where the items will be used (if different from (g))

SECTION2: ITEMS (goods, software, technology)

(a) Description of the item(s) (e.g. Name of Manufacturer /Model, Class, Type, Serial Number) (b) Quantity/Weight




(c) Contract Number / Date of signature of contract /

(a) The item(s) indicated in SECTION2 will be used for

(b) The above-mentioned Item(s) and/or replica thereof will not be used for the development, production and/or use of the weapons of mass destruction (WMD) namely nuclear weapon, chemical weapon, biological weapon and WMD delivery systems such as missiles, nor be used in any nuclear explosive activity, nuclear fuel-cycle activity and/or heavy water production which is not covered by IAEA safeguards. The items will be used for civil purpose only.

(c) The above-mentioned item(s) will be used by the end-user indicated in SECTION1 only and remain / be consumed in (country of final destination)

(d) We (I) shall not re-export the above-mentioned item(s). In the event we (I) have to re-export the item(s), we shall obtain prior consent of

(the name of the exporter) who was obliged by METI.

(e) (When the above-mentioned Item(s) include(s) technology - yes), it will be treated as strictly confidential.

(f) Additional Commitment(s):

(g) The ownership and/or rights to use of the above-mentioned item(s) will only be transferred 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 conduct civil business activities.

(h) We (I) were (was) explained and surely understand the contents of “Notice relating to EUC” from METI.

Signature by the president / authorized person of the company/organization

Name of the company/organization, Name and title of signer in block letters


(If you need to use continuation sheets, each must be signed by the same person who signs this form)

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