[별지 제2호 서식]

Annexed paper No. 2

Republic of Korea Ministry of ( )	STATEMENT BY ULTIMATE CONSIGNEE AND PURCHASER
① Ultimate Consignee	② Exporter
Name	Name
Address	Address
City		Country		City		Country
③ Commodities
We have placed orders with the person or firm named in ② for commodities indicated below.
ITEM(Model No. and Type)		QUANTITY
④ Disposition or use of items by Ultimate consignee named in ① (check and complete appropriate box(es))
We certify that the item(s) listed in ③ :
a. □ Will be used by us (as capital equipment) in the form in which received in a manufacturing process in the country named in ① and will not be reexported or incorporated into an end product.
b. □ Will be processed or incorporated by us into the following product(s) ___________________________________________(Specify) to be manufactured in the country named in ① for distribution in ___________________________.(Name of country or countries)
c. □ Used to service the following commodities _______________________________________________(Specify computers, aircraft, etc.) in the following destinations ____________________________.
d. □ Will be resold by us in the form in which received in the country named in ① for use or consumption therein. The specific end-use by my customer will be ______________________________________________ (Specify, if known)
e. □ Will be reexported by us in the form in which received to __________________________________.(Name of country or countries )
f. □ Other (Describe fully)
⑤ NATURE OF BUSINESS OF ULTIMATE CONSIGNEE
A. The nature of our business is(e.g. distributor, manufacturer, wholesaler, value added original equipment retailor, etc) B. Our business relationship with the korean exporter is(eg contractual, franchise, distributor, wholesaler, regular customer, etc) and we have had this business relationship for years
⑥ STATEMENT OF ULTIMATE CONSIGNEE AND PURCHASER We certify that all of facts contained in this statement are true and correct to the best of our knowledge and belief and we do not know of any additional facts which are inconsistent with the above statement. We shall promptly send a supplemental statement to the person named in ②, disclosing any change of facts of intentions set forth in this statement which occurs after the statement has been prepared and forwarded. Except as specifically authorized by the 「Foreign Trade Act」, we will not reexport, resell, or otherwise dispose of any commodities listed in ③ above : (1) to any country not approved for export as brought to our attention by means of a bill of lading, commercial invoice, or any other means ; or (2) to any person if there is reason to believe that it will result directly or indirectly, in disposition of the commodities contrary to the representations made in this statement or contrary to 「Foreign Trade Act」.
⑦ SIGNATURE OF ULTIMATE CONSIGNEE (OR COMPANY SEAL)	⑧ SIGNATURE OF PURCHASER (OR COMPANY SEAL)
NAME OF OFFICIAL		NAME OF OFFICIAL
TITLE OF OFFICIAL		TITLE OF OFFICIAL
DATE(mm dd, yyyy)		DATE(mm dd, yyyy)
Additional information (Any material facts which will be of value considering this statement)		Assistance in preparing statement
⑦, ⑧ are to be signed by the ultimate consignee shown in ① and by the Purchaser where the latter is not the same as the ultimate consignee. Where the ultimate consignee is unknown, ⑧ should be signed by the purchaser
⑨ CERTIFICATION FOR USE OF REPUBLIC OF KOREA EXPORTER We certify that no corrections, additions, or deletions were made on this form by us after this form was signed by the ultimate consignee and purchaser
SIGNATURE OF PERSON AUTHORIZED TO CERTIFY FOR EXPORTER (OR OFFICIAL SEAL)
NAME OF PERSON SIGNING THIS DOCUMENT	TITLE OF PERSON SIGNING THIS DOCUMENT	DATE(mm dd, yyyy)