Original Headed Paper of End User

END USER STATEMENT

The undersigned company (name and address)
………………….………
running the activity of:………………….............……………………………………

declares to import the following goods supplied by the Italian company
…………………………………………………………………………………………......

• Description of goods:
…………………………………………………………………………………............

(If the items are in a large number they can be listed in an annex)
• Quantity:……………………………………………………………………….
• Value: ………………………………………………………………………….
• Contract/Order number: ……………………………………………………….
• Date of signature: ……………………………………………………………...
• Specific purposes for which the goods are to be used
 (If the goods are to be incorporated into another product, then that product and its use should also be described)   ....………………………………………………...........................................................
…………………………………………………………………………………......................

The above said goods are assigned exclusively for civil purposes and will not be used for: 

capital punishment, torture or other cruel, inhuman or degrading treatment or punishment on a human being.

The above mentioned material will be used in the following place: ( address )
………………………………………………………………………………………….

The undersigned company undertakes not to sell, not to transfer, nor to divert during the  shipment and neither to re-export to other countries, nor even in their own and declares  that  a  statement of taking charge of goods, duly legalized, will be issued once goods are received. 

Said statement is issued exclusively on request of Italian licensing officers and will not mean acceptance of the conditions in which the goods are received.

Company Stamp                                                                                                  Legal Representative

                                                                                        Signature: …………………………………..
                                                                         (Print name, surname and title of signatory in capital)
Date