ソーラボジャパン株式会社〒179-0081 東京都練馬区北町 3-6-3
Tel：03-6915-7701
e-mail：sales@thorlabs.jp(代表)

輸出貿易管理令に関する該非判定書作成に関するお願い
該非判定書の発行につきましては、次項の同意事項への同意と情報のご提供を返信にて頂き、内容が確認でき次第に作成をさせて頂いております。 海外での最終使用者の把握による政府の定める輸出禁止国への拡散防止、禁止用途への使用の事前防止のため、また、弊社の多くの米国製品に関しては、米国輸出管理規制に照らして管理する必要がありご協力を頂いております。なお通常作成には 1 週間前後のお時間を頂戴しており、様式は弊社様式でのみの発行となりますので予めご了承ください。

Ａ．同意事項① 当該製品について、核兵器、化学兵器、生物兵器またはその他武器（以下兵器等という）にかかわる開発、製造、使用または保存等には使用しません。
② 最終使用者が、兵器等の開発、製造、使用または保存等に一切関わっていません。
③ 上記①および②の禁止事項に関して、お客様の責任で遵守させます。
(該当する□欄にチェックしてください)
これらＡ項①②③の全てについて、同意します

同意しません

Ｂ．必要情報の提供
1 から 5 の全てについてご記入ください。

1. 弊社製品型番(対象製品をすべてご記入ください)
2. 輸出国3. 輸出先（機関、使用者）

4. 使用用途

5. お客様の情報（ご依頼者様の所属、氏名および連絡先）

日付
ご担当者様名以上ご理解のほど、よろしくお願いいたします。

年月日

SALES (973) 300-3000
FAX (973) 300-3600
Date: __________

56 Sparta Ave, Newton, NJ 07860-0366Company Name _________________

PO #______________

TS/TQ #_____________________Part Numbers of controlled items under Export Administration Regulations (EAR):
In order to comply with U.S export control laws and regulations, a product-specific export licensefrom the U.S. Department of Commerce may or may not be required before exporting products
purchased from Thorlabs or any of its US divisions or foreign subsidiary offices based on end-use
and or ultimate destination. For these reasons, the complete name of the end user, specific end
use and the country of ultimate destination are required.
A signed fax copy may be sent to +81-3-6915-7716 or emailed to techsupport.jp@thorlabs.com. We willfinalize any pending order upon receipt and acceptance of the End User Statement.
1. End User’s Name: Person:
2. End User’s Phone and Email :3. End User’s Company Name :4. Street Address:
5. City/State/Zip Code/Postal Code:
6. Country:
7. Web Address:
8. End User’s type of business:
9. End user’s intended use and application of product:

10. Is the End-user the armed forces or internal security forces of its country? YES or NO
As an authorized signer for the company named above and on behalf of the company named above, I theundersigned hereby:
A. Recognize that the products to be purchased in accord with this statement remain subject to U.Sand JAPAN export laws and regulations even after such products are exported from the U.S.;
B. Certify that such products and any related technical data will not be transshipped, diverted, exported,
re-exported or otherwise transferred in contravention to U. S. export laws and regulations
C. Affirm that such products will not be used, directly or indirectly, in any application involving missile
technology, nuclear or chemical and biological weapons proliferation activities; andD. Without Thorlabs’ consent, will not directly or indirectly transfer, transmit, send, export
and/or re-export any of our items to Cuba, Iran, Syria, North Korea, Sudan, Iraq& Libya
E. Attest that the information provided in this statement is true and correct to the best of my knowledge
and belief-----------------------------------------Print Name--------------------------------------------Signature---------------------------------------------------------------------------------

Title

DateThorlabs, Inc.
56 Sparta Ave, Newton NJ 07860, Phone # (973) 300-3000 Fax # (973) 300-3600

ISO DOC# SA-EUS-FM-001 REVA 12/26/2012

記 入 見 本

SALES (973) 300-3000
FAX (973) 300-3600
Date: __________

56 Sparta Ave, Newton, NJ 07860-0366

弊社使用欄

Company Name _________________

弊社使用欄
PO #______________

弊社使用欄
TS/TQ #_____________________Part Numbers of controlled items under Export Administration Regulations (EAR):
In order to comply with U.S export control laws and regulations, a product-specific export licensefrom the U.S. Department of Commerce may or may not be required before exporting products
purchased from Thorlabs or any of its US divisions or foreign subsidiary offices based on end-use
and or ultimate destination. For these reasons, the complete name of the end user, specific end
use and the country of ultimate destination are required.

太枠内の項目に最終使用者の方の情報を英語でご記入ください

A signed fax copy may be sent to +81-3-6915-7716 or emailed to sales@thorlabs.jp. We will finalize any
pending order upon receipt and acceptance of the End User Statement.
1. End User’s Name: Person:(最終使用者様 氏名)

2. End User’s Phone and Email :(最終使用者様 電話番号&Email アドレス )3. End User’s Company Name :(最終使用者様 会社名)

4. Street Address:(最終使用者様 住所)

5. City/State/Zip Code/Postal Code:(最終使用者様 郵便番号)

6. Country:(最終使用者様 国名)7. Web Address:(最終使用者様 ホームページ)

8. End User’s type of business:(最終使用者様 業種)

9. End user’s intended use and application of product:（最終使用者様のご用途）※詳細にご記入ください。

10. Is the End-user the armed forces or internal security forces of its country? YES or NO（最終使用者様は、その国の軍もしくは治安部隊に所属していますか？）As an authorized signer for the company named above and on behalf of the company named above, I theundersigned hereby:
A. Recognize that the products to be purchased in accord with this statement remain subject to U.Sand JAPAN export laws and regulations even after such products are exported from the U.S.;
B. Certify that such products and any related technical data will not be transshipped, diverted, exported,
re-exported or otherwise transferred in contravention to U. S. export laws and regulations
C. Affirm that such products will not be used, directly or indirectly, in any application involving missile
technology, nuclear or chemical and biological weapons proliferation activities; andD. Without Thorlabs’ consent, will not directly or indirectly transfer, transmit, send, export
and/or re-export any of our items to Cuba, Iran, Syria, North Korea, Sudan, Iraq& Libya
E. Attest that the information provided in this statement is true and correct to the best of my knowledge
and belief(最終使用者様氏名)-----------------------------------------Print Name

(最終使用者様直筆署名)--------------------------------------------Signature(最終使用者様役職)(日付)---------------------------------------------------------------------------------

Title

Date

Thorlabs, Inc.
56 Sparta Ave, Newton NJ 07860, Phone # (973) 300-3000 Fax # (973) 300-3600

ISO DOC# SA-EUS-FM-001 REVA 12/26/2012