EXPORT LICENSE APPLICATION

BUREAU OF INDUSTRY AND SECURITY (BIS)

U.S. Department of Commerce

SECTION 1: APPLICANT INFORMATION

Full Legal Name of Applicant:
[________________________________]

Doing Business As (DBA):
[________________________________]

DUNS Number:
[________________________________]

Tax Identification Number (EIN/SSN):
[________________________________]

Street Address:
[________________________________]
[________________________________]

City: [____________________] State: [____] ZIP: [__________]

Country: [____________________]

Telephone: [____________________] Fax: [____________________]

Email: [________________________________]

Website: [________________________________]

Contact Person for This Application:
Name: [________________________________]
Title: [________________________________]
Phone: [____________________]
Email: [________________________________]

SECTION 2: TYPE OF APPLICATION

☐ Standard Export License
☐ Reexport License
☐ Transfer (In-Country)
☐ Special Comprehensive License (SCL)
☐ Encryption License Arrangement (ELA)
☐ License Exception Notification

Is this application related to a previously issued license?
☐ Yes ☐ No

If Yes, previous license number: [____________________]

SECTION 3: ITEM DESCRIPTION

Item 1:

Description of Item:
[________________________________]
[________________________________]
[________________________________]

Export Control Classification Number (ECCN):
[____________________]

Harmonized Tariff Schedule (HTS) Number:
[____________________]

Quantity: [____________________]

Unit of Measure: [____________________]

Value (USD): $[____________________]

End-Use Description:
[________________________________]
[________________________________]
[________________________________]

Technical Specifications:
[________________________________]
[________________________________]

Item 2 (if applicable):

Description of Item:
[________________________________]

ECCN: [____________________]

HTS Number: [____________________]

Quantity: [____________________]

Value (USD): $[____________________]

(Attach additional sheets if necessary)

SECTION 4: PARTIES TO THE TRANSACTION

A. Purchaser/Buyer

Name: [________________________________]

Address:
[________________________________]
[________________________________]

Country: [____________________]

Telephone: [____________________]

Email: [________________________________]

Government Affiliation (if any): [________________________________]

B. Intermediate Consignee (if applicable)

Name: [________________________________]

Address:
[________________________________]
[________________________________]

Country: [____________________]

Role in Transaction: [________________________________]

C. Ultimate Consignee/End-User

Name: [________________________________]

Address:
[________________________________]
[________________________________]

Country: [____________________]

Telephone: [____________________]

Email: [________________________________]

Type of Entity:
☐ Private Company
☐ Government Entity
☐ Educational/Research Institution
☐ Individual
☐ Other: [____________________]

Government Affiliation (if any): [________________________________]

SECTION 5: END-USE CERTIFICATION

Describe the specific end-use of the item(s):
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Will the item(s) be:

Used in development, production, or use of weapons of mass destruction?
☐ Yes ☐ No

Used for military end-use?
☐ Yes ☐ No

Resold or transferred to another party?
☐ Yes ☐ No

If Yes, describe: [________________________________]

Country of Ultimate Destination: [____________________]

SECTION 6: SCREENING CERTIFICATIONS

A. Denied Persons/Entities Screening

I certify that I have screened all parties to this transaction against:

☐ Denied Persons List
☐ Entity List
☐ Unverified List
☐ Military End-User (MEU) List
☐ Specially Designated Nationals (SDN) List
☐ Debarred Parties List

Results of screening:
☐ No matches found
☐ Match found - explanation attached

B. Red Flag Checklist

Have you encountered any of the following "red flags"?

☐ Customer declines installation, training, or maintenance services
☐ Customer is willing to pay cash for high-value items
☐ Customer unfamiliar with product's performance characteristics
☐ Delivery dates are vague or deliveries are to remote destinations
☐ Product capability does not fit the customer's line of business
☐ Customer requests excessive spare parts
☐ Customer evasive about end-use or end-user
☐ Intermediary refuses to identify end-user
☐ Requests for shipment to freight forwarder or intermediate country

If any boxes are checked, provide explanation:
[________________________________]
[________________________________]

SECTION 7: SUPPORTING DOCUMENTS CHECKLIST

☐ End-User Statement/Certificate
☐ Purchase Order/Contract
☐ Technical Specifications/Data Sheets
☐ Statement of Ultimate Consignee and Purchaser (BIS-711)
☐ Import Certificate (if required by destination country)
☐ Power of Attorney (if filed by agent)
☐ Previous License (if amendment/renewal)
☐ Other: [________________________________]

SECTION 8: SPECIAL CONDITIONS/REQUESTS

Request for expedited processing?
☐ Yes ☐ No

If Yes, provide justification:
[________________________________]
[________________________________]

Request for specific license conditions?
☐ Yes ☐ No

If Yes, describe:
[________________________________]

SECTION 9: CERTIFICATIONS AND DECLARATIONS

I, the undersigned, hereby certify that:

☐ All information provided in this application is true, accurate, and complete to the best of my knowledge and belief.

☐ I understand that false statements are punishable under 18 U.S.C. § 1001.

☐ I am authorized to submit this application on behalf of the applicant.

☐ I have conducted appropriate due diligence on all parties to this transaction.

☐ I understand that approval of this license does not relieve me of responsibility for compliance with all applicable laws and regulations.

☐ I will maintain records of this transaction for at least five (5) years as required by 15 CFR 762.

☐ I will comply with all license conditions and report any material changes in the transaction.

Signature: ________________________________

Printed Name: [________________________________]

Title: [________________________________]

Date: [__/__/____]

SECTION 10: FILING INFORMATION

Filing Method:
☐ SNAP-R (Simplified Network Application Process Redesign) - Preferred
☐ Paper submission to BIS

For SNAP-R submissions:
Access at: https://snapr.bis.gov

For paper submissions, mail to:
Bureau of Industry and Security
U.S. Department of Commerce
14th Street and Pennsylvania Avenue, NW
Room 2099B
Washington, DC 20230

SECTION 11: PROCESSING TIMELINE

Standard Processing Time: 30-90 days

License Validity: Typically 4 years from date of issuance (unless otherwise specified)

Status Tracking:
- SNAP-R: Online status available
- STELA (System for Tracking Export License Applications): 1-202-482-2752

SOURCES AND REFERENCES

• Bureau of Industry and Security: https://www.bis.gov
• Export Administration Regulations: https://www.bis.gov/regulations
• SNAP-R Portal: https://snapr.bis.gov
• Consolidated Screening List: https://www.trade.gov/consolidated-screening-list
• Commerce Control List: 15 CFR Part 774, Supplement No. 1

LEGAL NOTICES

Warning: Willful violation of the Export Administration Regulations may result in criminal penalties up to $1,000,000 and 20 years imprisonment per violation. Civil penalties may be up to $300,000 per violation or twice the value of the transaction, whichever is greater.

This template is provided for educational and informational purposes only. It should be reviewed and customized by qualified legal counsel familiar with export control laws before use.