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SCHEDULE
"C"
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Following
your completion of this Schedule:
click
here or go to www.securesearchinc.com/send.htm
for instructions on how
to send this
form to us. Thank you.
SECURESEARCH, INC.
SCHEDULE “C”
END-USER
CERTIFICATE
(REQUIRED BY THE GOVERNMENT OF CANADA, DEPARTMENT OF FOREIGN AFFAIRS AND
INTERNATIONAL TRADE, EXPORT CONTROLS DIVISION, OTTAWA, ONTARIO, CANADA)
When completed signed and
sworn, this is a legal document required for supervision and control of
international trade in regulated products. Violation of government
regulations may result in severe penalties and sanctions being imposed
in breach of national and international laws! Two copies of this
document are to be returned to SECURESEARCH, INC. or to our authorized
sales representative by registered mall, before any goods can be
shipped. In certain cases, based on the information in this
certificate, shipment may require issuance of a federal export
certificate or approval by the U.S. Department of Commerce.
 1.
Name of Canadian exporter (Securesearch, Inc. or): Securesearch, Inc.
 2.
Name of Importer:________________________________________________
 Address:_________________________________________________________
 Telephone
number including country code and area code:__________________
  Fax
number of Importer: ___________________ E-mail
address:_________________________________
3.
(U.S.A. purchasers ONLY) MANDATORY I.R.S. Employer Tax ID
no.(EIN) if importer is a company or agency:
 Social
Security Number if importer is an
individual:_____________________________
4. If importer is purchasing for sale to an authorized
third party, provide the name, address, phone number, fax number of
the third party:
 ____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
 (in
the U.S.A. please provide the third party Federal Employer ID no. or
Social Security Number):
 5.
If goods are to be exported to a THIRD country, provide name and address
of exporter:
 Name
& address of third country IMPORTER, if applicable:
___________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
6. END-USER IDENTIFICATION
Name of company or government agency/dept. designated as
the end-user (final purchaser) of these goods:
_____________________________________________________________________________________________
  Division:________________________
Phone number:___________________ Phone ext. no. if applicable:_______
  Fax
number:_______________________ E-mail
address:______________________________________________
Full
street address of end user (Not a post office box
no.):______________________________________________
______________________________________________________________________________________________
   P.O.
Box no.:______________ City:__________________
Country:____________________
Postal Code:____________________
 7.
Brief description of goods
purchased:_____________________________________________________________
______________________________________________________________________________________________
8.
End use purpose for which goods are being
purchased:______________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
 Purchase
order no.:__________________________________
9.
Affirmation: "I certify that the Securesearch, Inc. products described
above are only for use in (country name):
and will not be exported to any other country. We are the
end-user".
________________________________________________________________________
AUTHORIZED SIGNATURE
(PRINT OR TYPE YOUR NAME)
TITLE
________________________________________________________________________
Witness
name Witness
Signature Date
Affix
official stamp or seal of witness
taking sworn oath here:
Following
your completion of this Schedule:
go
to www.securesearchinc.com/send.htm
for
instructions on how to send this
form to us. Thank you.
End of
Schedule "C"
(Rev. 10-11/2007)
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