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OMB APPROVAL NO. 1405-0092
EXPIRATION DATE: 09/30/2008
*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, D.C. 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
Copy of DoS License with PM/DDTC Proviso(s)
DSP-62
Optional Documents
22 CFR § 126.13 Certification Letter
22 CFR § 127.11 Exception to Policy Letter
DTCC Acknowledgement Letter
Other Amplifying Data
Other DSP-62 Authorizations
Purchase order submitted with original license
DSP-62
Errors
U.S. DEPARTMENT OF STATE
DIRECTORATE OF DEFENSE TRADE CONTROLS
By selecting the "Submit" button, above, the Applicant hereby warrants the truthfulness of
all statements made herein and in accompanying documentation; acknowledges and understands
that, in accordance with 22 C.F.R. §127.2, it is unlawful to use any export or temporary
import control document containing a false statement or misrepresenting or omitting a
material fact for the purpose of exporting any defense article or technical data or the
furnishing of any defense service for which a license or approval is required by this
subchapter and that any false statement, misrepresentation, or omission of material fact in
an export control or temporary import control document will be consider as made in a matter
within the jurisdiction of a department or agency of the United States for the purposes of
18 U.S.C. 1001, 22 U.S.C. 2778 and 22 U.S.C. 2779; and that the applicant further agrees to
comply with all applicable provisions of 22 C.F.R. §120-130.
To cancel this submission, select "Cancel".
(If you cancel the submission, you will return to the previous page.)
Please be further advised, that if the "Submit" button is not active and you have already saved the
submission, you may not have completed all of the required fields. As a reminder you must save the
submission before you can submit.
DSP-62, Page
SEAL
1
of
Amendment Control No.
Signature
The Indicated License is
Amended Effective on:
The License identified in Block 4 below is amended as requested on the date
indicated at the right of this form.
DEPARTMENT OF STATE
UNITED STATES OF AMERICA
APPLICATION FOR AMENDMENT TO A DSP-61 LICENSE
*1. Date Prepared
02/04/2008
*2. PM/DDTC Applicant/Registrant Code
3. Applicant Name, Address, ZIP Code and Telephone Number
Subsidiary
*4. Amendment to License No.
I certify that the stated license has an unshipped balance and
has not expired.
*Name
*5. Amendment in accordance with (select one)
22 CFR § 123.25
*Attention
22 CFR § 122.4
6. Compliance Case Number
*Address
a. Provide Compliance Case Number
*City
*ZIP Code
*State
Ext
*Telephone #
b. Provide date of DTCC Acknowledgement Letter (mm/dd/yyyy)
7. Name and Telephone Number of applicant contact(s) familiar with
the application and proposed amendments if U.S. Government needs
additional information.
Name
Ext
Telephone #
Add
*8. Summary of Amendment(s) to DSP-61
9. Change Original PM/DDTC Applicant/Registrant Code (DSP-61 license, Block 2)
a. State specific reason for the change
b. PM/DDTC Applicant/Registrant Code as stated on DSP-61 license
c. New PM/DDTC Applicant/Registrant Code
10. Change Original Applicant/Subsidiary (DSP-61 license, Block 8)
Item #1:
a. Type of modification (select one)
b. State specific reason for the change
c. Applicant/Subsidiary as stated on original DSP-61 license
d. Modified Applicant/Subsidiary
Name
Name
Attention
Attention
Address
Address
City
City
State
Add
ZIP Code
State
ZIP Code
6
DSP-62, Page
2
of
6
11. Correction to Commodity Description (DSP-61 license, Block 12)
Item # 1:
a. Type of correction (select at least one)
Change part number
Correct typographical error
b. State specific reason for the change
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
Line Item #
Line Item #
Description
Description
Add
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
c. Change From - Quantity and/or $ Value as stated on original DSP-61
license
Line
Item #
Quantity
$ Value
Unit Price
Line Item Total
d. Change to - Quantity and/or $ Value as it should appear
Line
Item #
Unit Type
Quantity
$ Value
Unit Price
Line Item Total
Unit Type
Add
13. Revised DSP-61 License Total (DSP-61 license, Block 15)
a. Enter total $ value as stated on original DSP-61 license in Block 15
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)
Item # 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
b. State specific reason for the change
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
Name
Name
Address
Address
City
City
Country
Country
Add
DSP-62, Page
3
of
6
15. Change in Manufacturer of Commodity (DSP-61 license, Block 17)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Manufacturer of Commodity as stated on original DSP-61 license
d. New/Modified Manufacturer of Commodity
Name
Name
Address
Address
City
City
State
ZIP Code
Country
State
ZIP Code
Country
Add
16. Change in Source of Commodity (DSP-61 license, Block 19)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Source of Commodity as stated on original DSP-61 license
d. New/Modified Source of Commodity
Name
Name
Address
Address
City
City
State
ZIP Code
Country
State
ZIP Code
Country
Add
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
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
Name
Name
Address
Address
City
City
Country
Country
Add
DSP-62, Page
4
of
6
18. Change in Foreign Intermediate Consignee (DSP-61 license, Block 20)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Foreign Intermediate Consignee as stated on original DSP-61 license
d. New Foreign Intermediate Consignee
Name
Name
Address
Address
City
City
Country
Country
Add
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)
b. State specific reason for the change
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. U.S. Intermediate Consignee as stated on original DSP-61 license
e. New/Modified U.S. Intermediate Consignee
Name
Name
Address
Address
City
City
State
ZIP Code
State
ZIP Code
Add
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
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
Name
Name
Address
Address
City
City
Country
Add
Country
DSP-62, Page
5
of
6
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
c. Owner/End-User in Foreign Country of Ultimate Destination as stated on
original DSP-61 license
Name
d. Modified Owner/End-User in Foreign Country of Ultimate Destination
Address
Address
Name
City
City
Country
Country
Add
22. Additional Details of Transaction
* This application is related to a disclosure filed with Defense Trade Controls Compliance
No
Yes
Enter Compliance Disclosure Number:
*23. Applicant's Statement
, an empowered official (22 CFR § 120.25) or an official
I,
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 or 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)
a. I am authorized by the applicant to certify that the applicant and all of the parties to the transaction can meet in full the conditions of 22 CFR § 126.13
as listed above.
b. I am authorized by the applicant to certify to 22 CFR § 126.13. 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 above. A request for an exception to policy, as described in Section 127.11 of the ITAR, is attached.
c. I am authorized by the applicant to certify to 22 CFR § 126.13. 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 above. However that party has met the conditions imposed by the Directorate of Defense Trade Controls in order
to resume standard submission of applications, not requiring an exception to policy as described in Section 127.11 of the ITAR.
d. I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed above. The applicant and all of the parties to the transaction
can meet in full the conditions of 22 CFR § 126.13 as listed above. Please see the attached letter from an official that is authorized by the applicant to
certify to the conditions of 22 CFR § 126.13.
e. I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed above. 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 above. A request for an exception to policy, as described in Section 127.11 of the
ITAR, and a letter from an official that is authorized by the applicant to certify to the conditions of 22 CFR § 126.13 are attached.
f. I am not authorized by the applicant to certify the conditions of 22 CFR § 126.13 as listed above. 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 above. However that party has met the conditions imposed by the Directorate of
Defense Trade Controls in order to resume standard submission of applications, not requiring an exception to policy as described in Section 127.11 of the
ITAR. Please see the attached letter from an official that is authorized by the applicant to certify to the conditions of 22 CFR § 126.13.
Signature
Signature
24. Response to be sent to: (Enter Name, Address and phone number)
[Block is inactive on electronic form]
Name
Attention
Address
City
State
Telephone #
ZIP Code
Ext
DSP-62, Page
6
of
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.
6
DSP-62, Page
Subsidary Information under Block 3, Page 1 of the DSP-62
*Name
*Attention
*Address
*City
*State
*Telephone #
*ZIP Code
Ext
of
6
Complete List of Amendments under Block 8, Page 1 of the DSP-62
Total Number of Amendments Selected : 0
DSP-62, Page
6
of
6
Additional Applicant/Subsidiary Changes
1
of
DSP-62, Page
1
Change Original Applicant/Subsidiary (DSP-61 license, Block 8)
10. Change Original Applicant/Subsidiary (DSP-61 license, Block 8)
Item #2:
a. Type of modification (select one)
b. State specific reason for the change
c. Applicant/Subsidiary as stated on original DSP-61 license
d. Modified Applicant/Subsidiary
Name
Name
Attention
Attention
Address
Address
City
City
State
ZIP Code
State
ZIP Code
10. Change Original Applicant/Subsidiary (DSP-61 license, Block 8)
Item #3:
a. Type of modification (select one)
b. State specific reason for the change
c. Applicant/Subsidiary as stated on original DSP-61 license
d. Modified Applicant/Subsidiary
Name
Name
Attention
Attention
Address
Address
City
City
State
ZIP Code
State
ZIP Code
6
of
6
Additional Contacts Information
of
DSP-62, Page
0
Additional Applicant Contact Information
Name
Telephone #
Name
Ext
Name
Telephone #
Ext
Ext
Ext
Ext
Ext
Ext
Telephone #
Ext
Telephone #
Ext
Telephone #
Ext
Telephone #
Ext
Name
Ext
Name
Telephone #
Ext
Name
Name
Telephone #
Telephone #
Name
Name
Telephone #
Ext
Name
Ext
Name
Telephone #
Telephone #
Name
Name
Telephone #
Ext
Name
Name
Telephone #
Telephone #
Name
Name
Telephone #
Ext
Name
Name
Telephone #
Telephone #
Telephone #
Ext
Name
Ext
Telephone #
Ext
of
6
Additional Commodity Description Changes
of
DSP-62, Page
0
Correction to Commodity Description (DSP-61 license, Block 12)
11. Correction to Commodity Description (DSP-61 license, Block 12)
Item # 0:
a. Type of correction (select at least one)
Change part number
Correct typographical error
b. State specific reason for the change
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
Line Item #
Line Item #
Description
Description
11. Correction to Commodity Description (DSP-61 license, Block 12)
Item # 1:
a. Type of correction (select at least one)
Change part number
Correct typographical error
b. State specific reason for the change
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
Line Item #
Line Item #
Description
Description
of
6
Additional Quantity and/or $ Value Changes
of
DSP-62, Page
0
of
6
Correction to Quantity (DSP-61 license, Block 11) and/or $ Value (DSP-61 license, Block 14)
12. Correction to Quantity (DSP-61 license, Block 11) and/or $ Value (DSP-61 license, Block 14)
Item # 0:
a. Type of correction (select at least one)
Correct Quantity
Correct $ Value
b. State specific reason for the change
c. Change From - Quantity and/or $ Value as stated on original DSP-61
license
Line
Item #
Quantity
$ Value
Unit Price
Line Item Total
d. Change To - Quantity and/or $ Value as it should appear
Line
Item #
Unit Type
Quantity
$ Value
Unit Price
Line Item Total
Unit Type
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
c. Change From - Quantity and/or $ Value as stated on original DSP-61
license
Line
Item #
Quantity
$ Value
Unit Price
Unit Type
Line Item Total
d. Change to - Quantity and/or $ Value as it should appear
Line
Item #
Quantity
$ Value
Unit Price
Unit Type
Line Item Total
Additional Owner/End-User changes
of
DSP-62, Page
0
of
6
Change Name, Address and/or City of Original Owner/End-User of Commodity in Foreign
Country from which Shipped (DSP-61 license, Block 16)
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)
Item # 0:
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
b. State specific reason for the change
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement 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
Name
Name
Address
Address
City
City
Country
Country
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)
Item # 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
b. State specific reason for the change
c. For any change where the license is in furtherance of an agreement, the applicant has completed the amendment to the agreement 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
Name
Name
Address
Address
City
City
Country
Country
Additional Manufacturer of Commodity Changes
of
DSP-62, Page
0
Change in Manufacturer of Commodity (DSP-61 license, Block 17)
15. Change in Manufacturer of Commodity (DSP-61 license, Block 17)
Item # 0:
a. Type of modification (select one)
b. State specific reason for the change
c. Manufacturer of Commodity as stated on original DSP-61 license
d. New/Modified Manufacturer of Commodity
Name
Name
Address
Address
City
City
State
ZIP Code
Country
State
ZIP Code
Country
15. Change in Manufacturer of Commodity (DSP-61 license, Block 17)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Manufacturer of Commodity as stated on original DSP-61 license
d. New/Modified Manufacturer of Commodity
Name
Name
Address
Address
City
City
State
Country
ZIP Code
State
Country
ZIP Code
of
6
Additional Source of Commodity Changes
of
DSP-62, Page
0
Change in Source of Commodity (DSP-61 license, Block 19)
16. Change in Source of Commodity (DSP-61 license, Block 19)
Item # 0:
a. Type of modification (select one)
b. State specific reason for the change
c. Source of Commodity as stated on original DSP-61 license
d. New/Modified Source of Commodity
Name
Name
Address
Address
City
City
State
ZIP Code
Country
State
ZIP Code
Country
16. Change in Source of Commodity (DSP-61 license, Block 19)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Source of Commodity as stated on original DSP-61 license
d. New/Modified Source of Commodity
Name
Name
Address
Address
City
City
State
Country
ZIP Code
State
Country
ZIP Code
of
6
Additional Original Consignor Changes
of
DSP-62, Page
0
of
6
Change Name, Address and/or City of Original Consignor in Foreign Country from which
Shipped (DSP-61 license, Block 18)
17. Change Name, Address and/or City of Original Consignor in Foreign Country from which Shipped (DSP-61 license, Block 18)
Item # 0:
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
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
Name
Name
Address
Address
City
City
Country
Country
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
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
Name
Name
Address
Address
City
City
Country
Country
Additional Foreign Intermediate Consignee Changes
of
DSP-62, Page
0
Change in Foreign Intermediate Consignee (DSP-61 license, Block 20)
18. Change in Foreign Intermediate Consignee (DSP-61 license, Block 20)
Item # 0:
a. Type of modification (select one)
b. State specific reason for the change
c. Foreign Intermediate Consignee as stated on original DSP-61 license
d. New Foreign Intermediate Consignee
Name
Name
Address
Address
City
City
Country
Country
18. Change in Foreign Intermediate Consignee (DSP-61 license, Block 20)
Item # 1:
a. Type of modification (select one)
b. State specific reason for the change
c. Foreign Intermediate Consignee as stated on original DSP-61 license
d. New Foreign Intermediate Consignee
Name
Name
Address
Address
City
City
Country
Country
of
6
Additional U.S. Intermediate Consignee Changes
of
DSP-62, Page
0
of
Change Name, Address, City, State and/or ZIP Code of Original U.S.
Intermediate Consignee (DSP-61 license, Block 21)
19. Change Name, Address, City, State and/or ZIP Code of Original U.S. Intermediate Consignee (DSP-61 license, Block 21)
Item # 0:
a. Type of modification (select one)
b. State specific reason for the change
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. U.S. Intermediate Consignee as stated on original DSP-61 license
e. New/Modified U.S. Intermediate Consignee
Name
Name
Address
Address
City
City
State
ZIP Code
State
ZIP Code
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)
b. State specific reason for the change
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. U.S. Intermediate Consignee as stated on original DSP-61 license
e. New/Modified U.S. Intermediate Consignee
Name
Name
Address
Address
City
City
State
ZIP Code
State
ZIP Code
6
of
Additional Consignee in Foreign Country Changes
DSP-62, Page
0
of
Change Name, Address, and/or City of Original Consignee in Foreign Country of
Ultimate Destination (DSP-61 license, Block 22)
20. Change Name, Address and/or City of Original Consignee in Foreign Country of Ultimate Destination (DSP-61 license, Block 22)
Item # 0:
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
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
Name
Name
Address
Address
City
City
Country
Country
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
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
Name
Name
Address
Address
City
City
Country
Country
6
Additional Owner/End-User in Foreign Country Changes
of
DSP-62, Page
0
of
6
Change Name, Address and/or City of Original Owner/End-User in Foreign Country of
Ultimate Destination (DSP-61 license, Block 24)
21. Change Name, Address, and/or City of Original Owner/End-User in Foreign Country of Ultimate Destination (DSP-61 license, Block 24)
Item # 0:
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
c. Owner/End-User in Foreign Country of Ultimate Destination as stated on
original DSP-61 license
Name
d. Modified Owner/End-User in Foreign Country of Ultimate Destination
Address
Address
City
City
Country
Country
Name
21. Change Name, Address, and/or City of Original Owner/End-User in Foreign Country of Ultimate Destination (DSP-61 license, Block 24)
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
c. Owner/End-User in Foreign Country of Ultimate Destination as stated on
original DSP-61 license
Name
d. Modified Owner/End-User in Foreign Country of Ultimate Destination
Address
Address
City
City
Country
Country
Name
Attachments pertaining to 22 CFR § 126.13 Certification Letter
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Attachments pertaining to 22 CFR § 127.11 Exception to Policy Letter
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Attachments pertaining to DTCC Acknowledgement Letter
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Attachments Pertaining to Other Amplifying Data
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Attachments pertaining to Other DSP-62 Authorizations
Attachment?:
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Copy of DoS License with PM/DDTC Proviso(s)
Attachment?:
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Attachments pertaining to the Purchase order submitted with original license
Attachment?:
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Are you sure you want to delete this page?
To continue and delete selection, select "YES". To cancel delete, select "NO".
After the page has been deleted, you will be automatically returned to the previous continuation
page (if you have 2 or more continuation pages) or to the main page for the Block for which the
additional page was added (if you have only one continuation page).
YES
NO
Are you sure you want to delete this page?
To continue and delete selection, select "YES". To cancel delete, select "NO".
After the page has been deleted, you will be automatically returned to the previous continuation
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additional page was added (if you have only one continuation page).
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| File Type | application/pdf |
| File Title | H:\Documents\sample_dsp62.xfdl |
| Author | lunsfordtr |
| File Modified | 2008-02-04 |
| File Created | 2008-02-04 |