Page 176 - McWane Poles Sales Manual 2024
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McWane Poles, A Division of McWane Inc.
If this order will be for domestic use/stock and not planned for Export from the U.S. at this time, please
check this box and sign and date the bottom of the document.
If the items are to be exported from the U.S., please continue below and answer questions fully, then
please sign and date document.
1. Will this product be used in/at/on a Nuclear Plant or Nuclear Proliferation, Bio-Chemical Plant or Bio-
Chemical Technology, Biological Weapons, Fire Arms or Ammunition, Explosives, Missile or Missile
Technology, or any Military Application?
YES NO
If yes, provide name and location of project:_________________________________________________
_____________________________________________________________________________________
2 Do you or the company own, or are you or the company involved with any other entity, that qualifies
under (1) above?
YES NO
If yes, explain:__________________________________________________________________________
_____________________________________________________________________________________
Will the products be destined or pass through any of the following prohibited Countries: Belarus, Cuba,
Eritrea, Iran, North Korea, Syria, Venezuela or any other country that is listed on the Department of
State country sanction and embargoes list located at:
https://www.treasury.gov/resource-center/sanctions/Programs/Pages/Programs.aspx
YES NO
If yes, explain:__________________________________________________________________________
_____________________________________________________________________________________
Signed: ____________________________________________
Title:____________________________________________
END-USE/END-USER FORM:
