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License Questionnaire
License Questionnaire

Advisory:

Purpose of This Form

The information provided on this form will be used to determine if an Export License from the United States Department of Commerce is required for Export. If it is determined that an Export License is required for the order, then the information provided below will be used to apply for a license.

Who May Complete This Form

This form needs to be completed by the End-User or an authorized Cisco Partner. It should be completed by the person most knowledgeable about the order.

When Should This Form be Submitted

This form should be submitted when you are advised by the Cisco Export Operations Team that an export, transfer, or use license is required for a booked Sales Order.

This information will not be used for marketing or sales purposes.

Please contact Export Operations for special instructions if no valid Sales Order exists (e.g., RFP only).

1.

Licenses may not be amended. No additions or changes are permitted once the application is submitted to the Bureau of Industry and Security. Ensure that all information entered is complete and accurate. If the License Data Submission Form is invalid or if additional information is required, the End-User will be contacted directly which will lengthen the time to process the license application.

2.

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

3.

Failure to provide complete and accurate information will cause your license application to be rejected.

4.

Once filed, the United States Government may process applications for up to 90 days (average 6 - 8 weeks). Approval is not guaranteed.

* Indicates mandatory fields

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First Name

Last Name

*Submitted by (e.g., First Name and Last Name ) :  

*Submitter e-mail Address (e.g., jdoe@example.com)

Submitter Cisco User ID ( If you have one )

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, etc.


Please separate email addresses by using commas. This is an optional field.

*Cisco Sales Order Number :   


End-User Identity and Function

*Are you a Government entity or are the Cisco products intended for Government end use?

Yes No

If YES, are you:

Federal
Local
Civil

If YES, please select the primary function/role of the Government entity from the list below :
Utilities, Telecommunications or Internet Service Provider
Banking or Financial Institution (e.g., Credit Unions, Savings and Loans)
Transportation
Broadcast or Entertainment
Educational Organization
Civil Health and Medical Organization
Retail or Wholesale
Manufacturing or Industrial (Non-Military Items)
Environmental Regulation/Protection
Labor, Community or Social Services
Sports, Culture, Travel or Tourism
Tax, Revenue or Finance (Country, State, City or Municipal)
Postal Services
Other please specify
Are you in an embargoed or restricted destination or entity? Yes No


*Is the End-User a Military entity or does he work with the Military? Yes No
If YES, complete all the following:

  1. Complete this License Data Submission Form.

  2. When you have completed this form, please complete the EPCI form.

  3. List all branches of the Military or Armed Forces that will use or have access to the network equipment.

If NO, continue with Parties to Transaction and complete the License Data Submission Form.

Parties to Transaction

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

*Purchaser Company Name and Address:

 

Name

   

Address 1

   

Address 2

   

City

   

State

   

Country

   

Zipcode

   
 

* Intermediate Consignee Company Name and Address:

Name

   

Address 1

   

Address 2

   

City

   

State

   

Country

   

Zipcode

   
 

*Ship to Company Name and Address:

 

Name

   

Address 1

   

Address 2

   

City

   

State

   

Country

   

Zipcode

   
 

*End-User Company Name and Address:

Please include a street address. We recognize that street addresses might not be available. If this is the case, please provide the closest intersection and/or recognizable landmarks used to locate the End-User.
Providing an incomplete address will only increase delays in order shipment.





 

Name

   

Address 1

   

Address 2

   

City

   

State

   

Country

   

Zipcode

   
 

Installation Address: Required if Installation Address is different than End-User Address.If multiple sites, list all site locations. Include floor and room number, if available.

Name

   

Address 1

   

Address 2

   

City

   

State

   

Country

   

Zipcode

   
 

*End-User URL address:
 e.g.,http://www.enduser.com
No email addresses.

  

*End-User Contact Name:

*End-User Contact Phone Number:

End Use Information/Description

Note:

Provide DETAILED descriptions below. This will help the U.S. Department of Commerce to process your license application quickly and correctly. This information will remain confidential, and will not be used for marketing or sales purposes.
Vague or insufficient descriptions will cause delays in delivery of your order.



*What is the intended end use of Cisco technology?

What will be done with this technology?

How will it serve the End-User?

 
   

*Describe the project, programs, functions and services that the encryption products will support.

Is this to build a new network or to update a previously existing one?

 
   

*Describe precisely the type of data that will be encrypted using Cisco technology. What is the nature and purpose of this data? How will the data serve the End-User?

PLEASE NOTE: Vague answers such as "e-mail, web, internet traffic (video & data), etc." will cause the License Questionnaire to be INVALID. This information is insufficient for preparing an Export License Application.

 
   

*List all government agencies/ ministries/ branches/ departments that have access to the data transmitted over the network.

Responses such as "Government of X country" will be deemed invalid. Which part of the government will use this product?

 
   

*Describe any End-User involvement with local, national or international law enforcement agencies.
 

Reminder:


This form is not an export license application. The data collected on this form will be used to determine if a license is necessary. If Cisco determines that an Export License is required, this form will be used to prepare an application for the necessary license. Once filed, the partner will be notified with a "Z number" and information on how to receive an update on the procedure. Please be advised that the United States Government may process applications for up to 90 days (average 6 - 8 weeks). Approval is not guaranteed.