Export Compliance Form

Indicates required field

Customer Name

Customer Address

End Use (brief description)

End User Name

End User Country

Requested Firmware Version

Part Number/Hardware for Installation

I hereby acknowledge that the hardware/and or firmware that Kollmorgen is supplying is EXPORT CONTROLLED. This firmware is controlled under Export Administration Regulations 3D201 / hardware 3A225 and is subject to the export control laws of the U.S. Government. Transfer of this software/hardware by any means to a foreign national or representative of foreign government or interest, whether in the U.S. or abroad, without an export license or other approval from the U.S. Government is prohibited. Violation of these export laws is subject to severe criminal penalties.

Company Name

Date*

2026-09-09

Your Name

Your Job Title

Distributor Name

Your Email

Your Phone #

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