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Enhanced Proliferation Control Initiative Form

Advisory:

This form must be completed by the end user (install site). Cisco Employees, Cisco Partners and Resellers are prohibited from completing this form for the end user.

Accurately complete the form. Incomplete or inaccurate completion will delay the transaction.

Upon Cisco's acceptance of the representation made herein, the assurance will remain in effect TWO YEARS from the date of signature.

The submission of an EPCI Assurance, though required, does not overcome the license requirement for government end users. If you have questions, please contact export@cisco.com.

Provide all information in English. Submissions containing abbreviations, acronyms or a P.O. Box number will be considered invalid.



I, the undersigned, as a duly authorized representative of the organization identified below, understand and agree to the conditions set forth below regarding the usage of Cisco hardware and/or software. I understand failure to fully complete this form may result in a delay.

SECTION I

NATURE OF BUSINESS OF END-USER

Please indicate in the spaces provided whether the facility identified below is engaged, directly or indirectly, in any of the following activities:

Select applicable answers.

GOVERNMENT, MILITARY, AND EDUCATIONAL INSTITUTION

a.

Government End-User, if "Yes" then you must also complete the License Data Submission Form.

Yes No

b.

Military End-User, if "Yes" then you must also complete the License Data Submission Form.

Yes No

c.

Educational Institution (e.g., Academy, Institution, University, etc.)

Yes No

NUCLEAR WEAPONS

a.

Designing, developing, fabrication or testing nuclear weapons or nuclear explosive devices

Yes No

b.

Designing, construction, fabrication, or operating the following facilities, or components for such facilities:

 

1.

Facilities for the chemical processing of irradiated special nuclear or source material.

Yes No

 

2.

Facilities for the production of heavy water.

Yes No

 

3.

Facilities for the separation of isotopes of special nuclear material.

Yes No

 

4.

Facilities for the fabrication of nuclear reactor fuel containing plutonium.

Yes No

MISSILES

a.

Designing, developing, production of or using rocket systems, space launch vehicles, and sounding rockets, or unmanned air vehicle systems (including cruise missile systems, target drones and reconnaissance drones), which are capable of delivery at least 500 kilograms payload to a range of at least 300 kilometers.

Yes No

CHEMICAL BIOLOGICAL WEAPONS

a.

Designing, developing, production, stockpiling, or using chemical or biological weapons, or precursors.

Yes No

SECTION II

SPECIFIC END-USE CONTEMPLATED BY CUSTOMER

Explain in detail, the end use of the product ( WARNING: FAILURE TO PROVIDE COMPLETE AND FULL EXPLANATIONS WILL DELAY ORDER FULFILLMENT )

  • What branches or departments will use the product?
  • What type of data is to be transmitted?
  • Is there any other information you have that will help us understand your business and nature in which you intend to use Cisco equipment?

SECTION III

EXPORT - RE-EXPORT ASSURANCE

Demonstrate agreement by selecting boxes.

1.

WE AGREE that the Cisco products may not be exported/re-exported to Cuba, Iran, North Korea, Sudan and Syria.

2.

WE AGREE not to resell, transfer, or re-export Cisco products without prior authorization from Cisco and or the U.S. Government to any party not eligible to receive U.S. commodities, software, and technical data.

3.

WE AGREE not to resell, transfer, or re-export Cisco products without prior authorization from Cisco and or the U.S. Government to any military entity of:

Albania, Armenia, Azerbaijan, Belarus, Cambodia, China (PRC), Georgia, Iraq, Kazakhstan, Kyrgyzstan, Laos, Macau, Moldova, Mongolian P.R., Russia, Tajikistan, Turkmenistan, Uzbekistan, Ukraine, Vietnam

SECTION IV

FUTURE END-USE ASSURANCE

Demonstrate agreement by selecting boxes.

The undersigned certifies that the Cisco commodities, software and technical data that are acquired will not be used directly or indirectly in the following activities:

1.

Designing, developing or fabricating nuclear weapons or nuclear explosive devices; or devising, carrying out, or evaluating nuclear tests or nuclear explosions.

2.

Designing, assisting in the design of, constructing, fabricating, or operating facilities for the chemical processing or irradiated special nuclear material, for the production of heavy water, for the separation of isotopes of any source and special nuclear material or specially designed for the fabrication of nuclear reactor fuel containing plutonium.

3.

Designing, assisting in the design of, constructing, fabricating, furnishing or modifying equipment for the fabrication of chemical or biological weapons, chemical precursors, viruses, viroids, bacteria, fungi or protozoa.

4.

Designing, assisting in the design of, constructing, fabricating or furnishing equipment for components specially designed, modified or adapted for use in such facilities.

5.

Training personnel in any of the above activities, without obtaining prior authorization from the U.S. Department of Commerce, Bureau of Export Administration.

SECTION V

POST SHIPMENT VERIFICATION AGREEMENT

Select applicable answer.


a.

WE AGREE to allow Cisco personnel, or agreed upon third party agent, to perform on-site post shipment verifications within 6-9 months following order fulfillment.

Yes No

b.

WE AGREE to use Cisco products and technology for the purpose of facilitating communications.

Yes No

c.

WE AGREE not to process or incorporate Cisco Systems, Inc. products and technology into secondary products which contribute to the design, development, production, stockpiling or use of nuclear, chemical/biological weapons or missiles.

Yes No


* Company/Organization Name:

 

Complete Company Address:
(NO P.O. BOXES)

 

    *Address1:

 

      Address2:

 

    *City:

 

    *State:

 

    *Country:

 

    *Zipcode:

 

* SUBMITTED BY (Please enter your full name):

 

YOUR TITLE/POSITION:

 

* YOUR E-MAIL ID (e.g., jdoe@enterprise.com.uk):

 

If the company name in your email address does not match the company you are submitting the form for, please explain in this box.

 
     

Please enter your Company URL (eg http://www.company.com):

 
     

Enter the Cisco Sales Order Number (optional):

 
     

Please enter your Cisco user ID (optional) If you do not have one and would like to register please go to http://tools.cisco.com/RPF/register/register.do :

 
     

Note: Please identify person(s) to be copied in subsequent correspondence (e.g., email@company.com).
Examples may include: Cisco Account Manager, Two-Tier Distributor contact, Reseller contact, System Integrator contact.
Please separate email addresses by using commas. This is an optional field.

 
     

SIGNATURE:
By placing your name in the signature box you are acknowledging your organization's acceptance and agreement of the listed conditions.

* First Name:

 

* Last Name: