DSP-62 Application For Amendment To a DSP-61 LIcense

Electronic Form Version Number: 0.02 OMB APPROVAL NO. ??????

EXPIRATION DATE MM-DD-YYYY

*ESTIMATED BURDEN: 30 minutes

*PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: Department of State (A/RPS/DIR) Washington, DC 20520.

U.S. DEPARTMENT OF STATE

APPLICATION FOR AMENDMENT TO A DSP-61 LICENSE

*Transaction Number:

Please note that an Asterisk (*) next to a field or block in a document designates a mandatory field or block.

No classified information can be included in this application. Classified information must be sent separately to PM/DDTC in accordance with the Defense Security Service guidelines.

Classified information is being sent under separate cover

To open a document, click on a document to highlight it and select the “Open Document” button. The document that you selected will open.

Required Documents Included Documents

DSP-62

Copy of DoS License

Open Document

Open Document

Optional Documents

22 CFR § 126.13 Eligibility Letter

DTCCAcknowledgement Letter

Other Amplifying Data

Other DSP-62 Authorizations

Purchase order submitted with original license

Open Documnt

SEAL

Amendment Control No.

(text box – auto assigned)

Signature

The License identified in Block 4 below is amended as requested on the date indicated at the right of this form.

The Indicated License is Amended Effective on:

(text box – auto assigned)

UNITED STATES OF AMERICA DEPARTMENT OF STATE APPLICATION FOR AMENDMENT TO A DSP-61 LICENSE

* mm/dd/yyyy 1. Date Prepared (text box – auto filled)

*2. PM/DDTC Applicant/Registrant Code

(text box)

3. Applicant Name, Address, ZIP Code and Telephone Number

* 4. Amendment to License No. (text box) I certify that the state license has an unshipped balance and has not expired.

(Check box) Subsidiary

A dd Subsidiary Information button

*5. Amendment in accordance with (select one)

*Name {text box}

22 CFR § 123.25

22 CFR § 122.4

6. Compliance Case Number

* Attention (text box)

a. Provide Compliance Case Number (text box, 10 characters)

*Address (text box)

* City (text box)

b. Provide date of DTCC Acknowledgement Letter (mm/dd/yyyy)

(text box)

* State (pick list)

* ZIP Code (text box)

*Telephone # (text box)

E xt (text box)

7. Name and Telephone Number of applicant contact(s) familiar

with the application and proposed amendments if U.S. Government

*8. Summary of Amendment(s) to DSP-61

needs additional information.

T View Full List ype of Amendment(s) (text box) - a multiple pick list

N ame (text box)

 Copy Selections(s)

T elephone # (text box)

E xt (text box)

Add More button

9. Change Original PM/DDTC Applicant/Registrant Code (DSP-61 license, Block 2)

State specific reason for the change (text box) 500 chars

b. PM/DDTC Applicant/Registrant Code as stated on DSP-61 license c. New PM/ DDTC Applicant/Registrant Code

(text box} 1 letter from a pick list of F, B, M, G, and 5 characters

(text box} 1 letter from a pick list of F, B, M, G, and 5 characters

10. Change Original Applicant/Subsidiary (DSP-61 license, Block 8)

Item # 1: (will have at most 2 items)

a. Type of modification (select one)

Change in name of original applicant

Add subsidiary

Change in name of original subsidiary

Change in address, city, state and/or ZIP code of original applicant

Delete subsidiary

Change in address, city, state and/or ZIP code of original subsidiary

Change in name, address, city, state and/or ZIP code of original applicant

Change in name, address, city, state and/or ZIP code of original subsidiary

State specific reason for the change (text box) 500 chars

c. Applicant/Subsidiary as stated on original DSP-61 license

d . Modified Applicant/Subsidiary

N ame (text box)

Name (text box)

A ddress (text box)

A ddress (text box)

City (text box)

C ity (text box)

S tate (pick list) ZIP Code (text box)

S tate (pick list) ZIP Code (text box)

Add More button

11. Correction to Commodity Description (DSP-61 license, Block 12)

Item # 1:

a. Type of correction (select at least one)

Change part number

Correct typo

If changing a part number, (appears only if change part number is selected)

I certify that the change in the part number does not enhance, upgrade, or change the capability of the commodity authorized for export.

b. State specific reason for the change

(text box) 500 chars

c. Change From – Commodity description to include the part number as stated on original DSP-61

d . Corrected Commodity description to include the part number

L ine item # (text box)(auto filled)

Line item # (text box )(auto filled)

D escription

D escription

(text box) 500 chars

(text box) 500 chars

Add More Items button

12. Correction to Quantity (DSP-61 license, Block 11) and/or $ Value (DSP-61 license, Block 14)

Item # 1:

a. Type of correction (select at least one)

Correct Quantity

Correct $ Value

b. State specific reason for the change

(text box) 500 chars

c. Change From – Quantity and/or $ Value as stated on original DSP-61 license

d. Change to – Quantity and/or $ Value as it should appear

Line Item #

Quantity

$ Value

Line Item #

Quantity

$ Value

Unit Price

Line Item Total

Unit Price

Line Item Total

(text box) (auto filled)

( text box) Unit Type (Pick List)

(text box) (text box) button

(text box) (auto filled)

( text box) Unit Type (Pick List)

(text box) (text box) button

Ad More button

1 3. Revised DSP-61 License Total ( DSP-61 license, Block 15)

a. Enter total $ value as stated on original DSP-61 license in Block 15

(text box) (text box) (Calculated from Block 13a and changes in Block 12)

b. Revised total $ value

14. Change Name, Address and/or City of Original Owner/End-User of Commodity in Foreign Country from which Shipped (DSP-61 license, Block 16)

I tem # 1

a. Type of modification (select at least one)

Change in name of original foreign end user

Change in address and/or city of original foreign end user

State specific reason for the change

(text box) 500 chars

c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR 124 to reflect this change. (select one) Yes No Not Applicable

d. Owner/End-User of Commodity in Foreign Country from which Shipped as stated on original DSP-61 license

e. Modified Owner/End-User of Commodity in Foreign Country from which Shipped

N ame (text box)

N ame (text box)

A ddress (text box)

A ddress (text box)

C ity (text box)

C ity (text box)

C ountry (pick list)

C ountry (pick list from left)

Add More Items

15. Change in Manufacturer of Commodity (DSP-61 license, Block 17)
Item # 1:
a. Type of modification (select one)
		Add new manufacturer				Change in name of original manufacturer
		Delete manufacturer				Change in address, city, state and/or ZIP code of original manufacturer
						Change in name, address, city, state and/or ZIP code of original manufacturer
If adding new manufacturer of commodity, (appears only if adding new manufacturer)
	I certify that the addition of the new manufacturer does not enhance, upgrade or change the capability of commodity(ies) authorized for export.
b . State specific reason for the change
(text box) 500 chars
c. Manufacturer of Commodity as stated on original DSP-61 license										d. New/Modified Manufacturer of Commodity
N ame (text box)										N ame (text box)
A ddress (text box)										A ddress (text box)
City (text box)										City (text box)
S tate (pick list)			Z IP Code (text box)							S tate (pick list)	Z IP Code (text box)
Country										Country
Add More button
16. Change in Source of Commodity (DSP-61 license, Block 19)
Item # 1:
a. Type of modification (select one)
		Add new source				Change in name of original source
		Delete source				Change in address, city, state and/or ZIP code of original source
						Change in name, address, city, state and/or ZIP code of original source
If adding new source of commodity, (appears only if adding new source)
	I certify that the addition of the new source does not enhance, upgrade or change the capability of commodity(ies) authorized for export.
b . State specific reason for the change
(text box) 500 chars
c. Source of Commodity as stated on original DSP-61 license										d. New/Modified Source of Commodity
N ame (text box)										N ame (text box)
A ddress (text box)										A ddress (text box)
City (text box)										City (text box)
S tate (pick list)			Z IP Code (text box)							S tate (pick list)	Z IP Code (text box)
Country										Country
Add More button
17. Change Name, Address and/or City of Original Consignor in Foreign Country from which Shipped (DSP-61 license, Block 18)
Item # 1:
a. Type of modification (select at least one)							Change in name of original foreign consignor
							Change in address and/or city of original foreign consignor
b . State specific reason for the change
(text box) 500 chars
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR 124 to reflect this change. (select one) Yes No Not Applicable
d. Consignor in Foreign Country from which Shipped as stated on original DSP-61 license										e. Modified Consignor in Foreign Country from which Shipped
N ame (text box)										N ame (text box)
A ddress (text box)										A ddress (text box)
City (text box)										City (text box)
C ountry (auto filled from left column)										Country (pick list from left)
Add More Items button

18. Change in Foreign Intermediate Consignee (DSP-61 license, Block 20)
Item # 1:
a. Type of modification (select one)
	Add new foreign freight forwarder					Change in name of original foreign intermediate consignee to include foreign freight forwarder
						Change in address and/or city of original foreign intermediate consignee to include foreign freight forwarder
						Change in name, address, city and/or country of original foreign intermediate consignee to include foreign freight forwarder
b . State specific reason for the change
(text box) 500 chars
c. Foreign Intermediate Consignee as stated on original DSP-61 license							d. New Foreign Intermediate Consignee
N ame (text box)							N ame (text box)
A ddress (text box)							A ddress (text box)
City (text box)							City (text box)
C ountry (auto filled from left column)							C ountry (if Add, text box otherwise auto filled from left column))
Add More Items button
19. Change Name, Address, City, State and/or ZIP Code of Original U.S. Intermediate Consignee (DSP-61 license, Block 21)
Item # 1:
a. Type of modification (select one)			Change in name of original U.S. intermediate consignee
			Change in address, city, state and/or ZIP code of original U.S. intermediate consignee
				Add new U.S. intermediate consignee
.b. State specific reason for the change. (Text Box, 100 characters max)
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR 124 to reflect this change.
Yes No Not Applicable
d. U.S. Intermediate Consignee as stated on original DSP-61 license							e. New / Modified U.S. Intermediate Consignee
N ame (text box)							N ame (text box)
A ddress (text box)							A ddress (text box)
City (text box)							City (text box)
S tate (pick list)		Z IP Code (text box)					S tate (pick list)	Z IP Code (text box)
Add More button
20. Change Name, Address and/or City of Original Consignee in Foreign Country of Ultimate Destination (DSP-61 license, Block 22)
Item # 1:
a. Type of modification (select at least one)					Change in name of original consignee in foreign country of ultimate destination
					Change in address and/or city of original consignee in foreign country of ultimate destination
b . State specific reason for the change
(text box) 500 chars
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement required by 22 CFR 124 to reflect this change. (select one) Yes No Not Applicable
d. Consignee in Foreign Country of Ultimate Destination as stated on original DSP-61 license							e. Modified Consignee in Foreign Country of Ultimate Destination
N ame (text box)							N ame (text box)
A ddress (text box)							A ddress (text box)
City (text box)							City (text box)
C ountry (auto filled from left column)							Country (pick list from left)
Add More button

21. Change Name, Address and/or City of Original Owner/End-User in Foreign Country of Ultimate Destination (DSP-61 license, Block 24)

Same as Block 14

Item # 1:

a. Type of modification (select at least one)

Change in name of original owner/end-user in foreign country of ultimate destination

Change in address and/or city of original owner/end-user in foreign country of ultimate destination

b . State specific reason for the change

(text box) 500 chars

c. Owner/End-User in Foreign Country of Ultimate Destination as stated on original DSP-61 license

d. Modified Owner/End-User in Foreign Country of Ultimate Destination

N ame (text box)

N ame (text box)

A ddress (text box)

A ddress (text box)

City (text box)

City (text box)

C ountry (auto filled from left column)

Country (pick list from left)

Add More button

22. Additional Details of Transaction

(text box) 1000 chars

*23. Applicant’s Statement

I , ___________________________, an empowered official (22 CFR § 120.25) or an official of a foreign government entity in the U.S., hereby apply for approval of the above amendment(s); warrant the truth of all statements made herein; and acknowledge, understand and will comply with the

provisions of 22 CFR 120-130, and any conditions and limitations imposed.

I am authorized by the applicant to certify the following in compliance with 22 CFR § 126.13:

(1)

Neither the applicant, its chief executive officer, president, vice presidents, other senior officers or officials (e.g., comptroller, treasurer, general counsel) nor any member of its board of directors is:

(a)

the subject of an indictment for or has been convicted of violating any of the U.S. criminal statutes enumerated in 22 CFR § 120.27 since the effective date of the Arms Export Control Act, Public Law 94-329, 90 Stat. 729 (June 30, 1976); or

(b)

ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an export license or other approval from any agency of the U.S. Government;

(2)

To the best of the applicant’s knowledge, no party to the export as defined in 22 CFR § 126.7 (e) has been convicted of violating any of the U.S. criminal statutes enumerated in 22 CFR § 120.27 since the effective date of the Arms Export Control Act, Public Law 94-329, 90 Stat. 729 (June 30, 1976), or is ineligible to contract with, or to receive a license or other approval to import defense articles or defense services from, or to receive an export license or other approval from any agency of the U.S. Government.

*22 CFR § 126.13 Certification (select one)

I am authorized by the applicant to certify that the applicant and all the parties to the transaction can meet in full the conditions of 22 CFR § 126.13 as listed in Block 23.

I am authorized by the applicant to certify to 22 CFR § 126.1.3. The applicant or one of the parties of the transaction cannot meet one or more of the conditions of 22 CFR § 126.13 as listed in Block 23. A request for an exception to policy is attached.

I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed in Block 23. The applicant and all the parties to the transaction can meet in full the conditions of 22 CFR § 126.13 as listed in Block 23. Please see the attached letter for such certification.

I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed in Block 23. The applicant or one of the parties of the transaction cannot meet one or more of the conditions of 22 CFR § 126.13 as listed in Block 23. A letter of such certification and request for an exception to policy is attached.

Signature Signature button

24. Response to be sent to: (Enter Name, Address and phone number)

[Block is inactive on electronic form]

N ame (text box)

Attention

A ddress (text box)

City (text box)

S tate (pick list)

Z IP Code (text box)

T elephone #

Ext (text box)

DSP-62, Page 6 or #

CONDITIONS OF ISSUANCE

1. When approved, all of the original conditions except as modified by the Directorate of Defense Trade Controls (DDTC) remain applicable.

2. This amendment, when approved, becomes a part of the license identified in Block 4 on Page 1 of this form. When returned to the applicant, it must be attached to the original license prior to further use of the license or must be provided to U.S. Customs and Border Protection for filing with the original license.

Subsidiary Information under Block 3, Page 1 of the DSP-62

Name
A ttention
A ddress
C ity
State State	ZIP Code
Telephone #	Extension