U.S. DEPARTMENT OF STATE APPLICATION FOR AMENDMENT TO A DSP-73 LICENSE

Transcription

1 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 (A/RPS/DIR) Washington, D.C U.S. DEPARTMENT OF STATE APPLICATION FOR AMENDMENT TO A DSP-73 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 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 DSP-74 Copy of DoS License Included Documents Open Document Optional Documents Open Document Open Document DSP Revised

2 DSP-74, Page 1 of SEAL Signature The License identified in Block 4 below is amended as requested on the date indicated at the right of this form. Amendment Control No. The Indicated License is Amended Effective on: UNITED STATES OF AMERICA DEPARTMENT OF STATE APPLICATION FOR AMENDMENT TO A DSP-73 LICENSE *1. Date Prepared 11/22/2004 *2. DDTC Applicant/Registrant Code 3. Applicant,, and Tel No. *4. Amendment to License No. * *Attention * * Subsidiary * *Telephone # * *7. and Telephone Number of applicant contact(s) familiar with the application and proposed amendents if U.S. Government needs additional information. Telephone # Add More Contacts Add Subsidiary Information I certify that the stated license has an unshipped balance and has not expired. *5. Amendment in accordance with (select one) 22 CFR CFR *6. Have you made your 22 CFR notification? (select one) If yes, a. Select purpose of 22 CFR notification (select one) Merger Yes Change Location Change b. Date of Notification (mm/dd/yyyy) c. Acquiring from Merged with Divisted from No Acquisition None Required *8. Summary of Amendment(s) to DSP-73 <== View Full List 9. Change Original DDTC Applicant/Registrant Code (Block 2) a. specific reason for the change b. DDTC Applicant/Registrant Code as stated on DSP-73 c. New DDTC Applicant/Registrant Code 10. Change Original Applicant/Subsidiary (Block 5) (will have at most 2 items) c. Applicant/Subsidiary as stated on originial DSP-73 license d. Modified Applicant/Subsidiary

3 DSP-74, Page 2 of 11. Correction to Commodity Description (Block 13) a. Type of correction (select at least one) Change part number Correct typo If changing a part number, I certify that the change in the part number does not enhance, upgrade, or change the capability of the commodity authorized for export. c. Change From - Commodity description to include the part number as d. Corrected Commodity description to include the part number stated on original DSP-73 Line Item # Line Item # Description Description 12. Correction to Quantity (Block 12) and/or $ Value (Block 15) a. Type of correction (select at least one) Correct Quantity Correct $ Value c. Change From - Quantity and/or $ Value as stated on originial DSP-73 license Line Item # Quantity $ Value Unit Price Line Item Total d. Change to - Quantity and/or $ Value as it should appear Line Item # Quantity $ Value Unit Price Line Item Total Unit Type Calculate Unit Type Calculate Add More Corrections 13. Revised DSP-73 License Total (Block 16): a. Enter total $ value as stated on original DSP-73 license in Block 16 b. Revised total $ value 14. Change in Manufacturer of Commodity (Block 17) If adding new manufacturer of commodity, I certify that the addition of the new manufacturer does not enhance, upgrade, or change the capability of the commodity(ies) authorized for export. c. Manufacturer of Commodity as stated on original DSP-73 license d. New/Modified Manufacturer of Commodity

4 DSP-74, Page 3 of 15. Change in Source of Commodity (Block 19) If adding new source of commodity, I certify that the addition of the new source does not enhance, upgrade or change the capability of commodity(ies) authorized for export. c. Source of Commodity as stated on original DSP-73 license d. New/Modified Source of Commodity 16. Change in Foreign Intermediate Consignee and/or Freight Fowarder (Block 18) c. Foreign Intermediate Freight Forwarder or Foreign Intermediate Consignee as stated on original DSP-73 license d. New Foreign Intermediate Freight Forwarder or Modified Foreign Intermediate Consignee 17. Change, and/or of Original Temporary Foreign Consignee (Block 20) a. Type of modification (select at least one) Change in name of original foreign consignee Change in address and/or city of original foreign consignee c. Temporary Foreign Consignee as stated on original DSP-73 license d. Modified Temporary Foreign Consignee Country Country Country Country

5 DSP-74, Page 4 of 18. Change in U.S. Consignor and/or U.S. Freight Forwarder (Block 21) c. U.S. Consignor and/or U.S. Freight Forwarder as stated on original DSP-73 license d. New/Modified U.S. Consignor or U.S. Freight Forwarder 19. Change,,, and/or of Original Temporary Foreign End User (Block 22) Change in name of original temporary foreign end user Change in address and/or city of original temporary foreign end user c. Temporary Foreign End-User as stated on original DSP-73 license d. Modified Temporary Foreign End-User Country Country 20. Change Aircraft/Vessel Commander (Block 29) c. Aircraft/Vessel Commander as written on original DSP-73 license or New Aircraft/Vessel Commander Add new commander Delete commander Aircraft or Vessel Information Item # FAA Reg # or Vessel Document # Commander Line Item # Operator or Cert License Number Country *Telephone #

6 DSP-74, Page 5 of 21. Additional Details of Transaction *22. Applicant's ment I,, an empowered official (ITAR ) 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 Title 22 CFR , and any conditions or limitations imposed. I am a responsible official empowered by the applicant to certify the following in compliance with 22 CFR : (1) Neither the applicant, its chief executive officer, president, vice presidents, other senior officers or officals (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 statues enumerated in 22 CFR since the effective date of the Arms Export Control Act, Public Law , 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 th export as defined in Section (e) has been convicted of violating any of the U.S. criminal statues enumerated in 22 CFR since the effective date of the Arms Export Control Act, Public Law , 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. Signature Signature 23. Response to be sent (Enter, and phone number) [This block is inactive on electronic form.] Attention Telephone #

7 DSP-74, 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 the Page 1 of this form. When returned to the applicant, it must be attached to the original license prior to filing with Bureau of Customs and Border Protection or must be sent to Bureau of Customs and Border Protection for filing with the original license.

8 DSP-74, Page 7 of Subsidary Information under Block 3, Page 1 of the DSP-74 Attention Zipcode Telephone #