End Use Statement FORM

FORM EU-100 AMALE International

175 n Purdue Ave, Oak Ridge TN 37830 USA Phone: [phone] Fax: [phone] END USE STATEMENT

NOTE: ALL LINES MUST BE COMPLETELY FILLED IN UNLESS OTHERWISE SPECIFIED. END USE STATEMENTS RECEIVED BY AMALE INTERNATIONAL WILL NOT BE ACCEPTED UNLESS COMPLETE, INCLUDING SIGNATURE, DATE AND TITLE OF PERSON COMPLETING THIS FORM.

Purchase Order Number __________________________________________________
Company/Facility Name: ___________________________________________ _______
Department in which equipment will be used: __________________________________________________
Specific End User: __________________________________________________
Complete Address of Facility: __________________________________________________ __________________________________________________ __________________________________________________
Phone Number_____________________________ Fax Number _______________________________________
Email ____________________________________ Company Website ___________________________________

The specific application of the equipment is as follows. Please describe in detail and use an additional sheet of paper if necessary.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Does this site contain a nuclear reactor? _______(yes/no)
Does this site contain special nuclear material? _______(yes/no)
(see page 2 for definition of special nuclear material)

Please advise if this facility is directly or indirectly involved in the development or stockpiling of any of the following. Indicate yes if this facility is involved in these facilities,