This form must be completed by the end user (install site).
Cisco Employees, Cisco Partners and Resellers are prohibited from completing this form for the end user.
Accurately complete the form. Incomplete or inaccurate completion will delay
the transaction.
Upon Cisco's acceptance of the representation made herein, the assurance
will remain in effect TWO YEARS from the date of signature.
The submission of an EPCI Assurance, though required, does not overcome
the license requirement for government end users. If you have questions, please
contact export@cisco.com.
Provide all information in English. Submissions containing abbreviations,
acronyms or a P.O. Box number will be considered invalid.
I, the undersigned, as a duly authorized representative of the organization
identified below, understand and agree to the conditions set forth below
regarding the usage of Cisco hardware and/or software. I
understand failure to fully complete this form may result in a delay.
SECTION I
NATURE OF BUSINESS OF END-USER
Please indicate in the spaces provided whether the facility identified
below is engaged, directly or indirectly, in any of the following activities:
Designing, developing, fabrication or testing nuclear weapons
or nuclear explosive devices
YES NO
b.
Designing, construction, fabrication, or operating the following
facilities, or components for such facilities:
1.
Facilities for the chemical processing of irradiated special
nuclear or source material.
YES NO
2.
Facilities for the production of heavy water.
YES NO
3.
Facilities for the separation of isotopes of special nuclear
material.
YES NO
4.
Facilities for the fabrication of nuclear reactor fuel containing
plutonium.
YES NO
MISSILES
a.
Designing, developing, production of or using rocket systems,
space launch vehicles, and sounding rockets, or unmanned air vehicle systems
(including cruise missile systems, target drones and reconnaissance drones),
which are capable of delivery at least 500 kilograms payload to a range
of at least 300 kilometers.
YES NO
CHEMICAL BIOLOGICAL WEAPONS
a.
Designing, developing, production, stockpiling, or using
chemical or biological weapons, or precursors.
YES NO
SECTION II
SPECIFIC END-USE CONTEMPLATED BY CUSTOMER
Explain in detail, the end use of the product ( WARNING: FAILURE TO PROVIDE COMPLETE AND FULL EXPLANATIONS WILL DELAY ORDER FULFILLMENT )
What branches or departments will use the product?
What type of data is to be transmitted?
Is there any other information you have that will help us understand your business and nature in which you intend to use Cisco equipment?
SECTION III
EXPORT - RE-EXPORT ASSURANCE
Demonstrate agreement by selecting boxes.
1.
WE AGREE that the Cisco products may not be exported/re-exported
to Cuba, Iran, North Korea, Sudan and Syria.
2.
WE AGREE not to resell, transfer, or re-export Cisco products
without prior authorization from Cisco and or the U.S. Government
to any party not eligible to receive U.S. commodities, software, and technical
data.
3.
WE AGREE not to resell, transfer, or re-export Cisco products without
prior authorization from Cisco and or the U.S. Government
to any military entity of:
The undersigned certifies that the Cisco commodities, software and technical data that are acquired will not
be used directly or indirectly in the following activities:
1.
Designing, developing or fabricating nuclear weapons or
nuclear explosive devices; or devising, carrying out, or evaluating nuclear
tests or nuclear explosions.
2.
Designing, assisting in the design of, constructing, fabricating,
or operating facilities for the chemical processing or irradiated special
nuclear material, for the production of heavy water, for the separation
of isotopes of any source and special nuclear material or specially designed
for the fabrication of nuclear reactor fuel containing plutonium.
3.
Designing, assisting in the design of, constructing,
fabricating, furnishing or modifying equipment for the fabrication of
chemical or biological weapons, chemical precursors, viruses, viroids,
bacteria, fungi or protozoa.
4.
Designing, assisting in the design of, constructing,
fabricating or furnishing equipment for components specially designed,
modified or adapted for use in such facilities.
5.
Training personnel in any of the above activities,
without obtaining prior authorization from the U.S. Department of Commerce,
Bureau of Export Administration.
SECTION V
POST SHIPMENT VERIFICATION AGREEMENT
Select applicable answer.
a.
WE AGREE to allow Cisco personnel,
or agreed upon third party agent, to perform on-site post shipment verifications
within 6-9 months following order fulfillment.
YES
NO
b.
WE AGREE to use Cisco products
and technology for the purpose of facilitating communications.
YES
NO
c.
WE AGREE not to process or incorporate Cisco
Systems, Inc. products and technology into secondary products which contribute
to the design, development, production, stockpiling or use of nuclear,
chemical/biological weapons or missiles.
YES
NO
Company/Organization Name:
Complete Company Address: (NO P.O. BOXES)
SUBMITTED BY (Please enter your full name):
YOUR TITLE/POSITION:
YOUR E-MAIL ID (e.g., jdoe@enterprise.com.uk):
If the company name in your email address does not match the company you are submitting the form for, please explain in this box.
Please enter your Company URL (eg www.company.com):
Enter The Sales Order Number (optional) Cisco Sales Order Number (e.g., 4XXXXXXX or 8XXXXXX )
Note: Please identify person(s) to be copied in subsequent
correspondence (e.g., email@company.com).
Examples may include: Cisco Account Manager, Two-Tier Distributor contact,
Reseller contact, System Integrator contact. Please
separate email addresses by using commas. This is an optional field.
SIGNATURE: By placing your name in the signature box you are acknowledging
your organization's acceptance and agreement of the listed conditions.
