End-Use Form — EMSI, Inc.

Dear Customer,

The items that you have requested, purchased or intend to purchase are subject to U.S. export regulations and laws. These laws and regulations include, but are not limited to, the U.S. Export Administration Regulations (EAR) administered by the U.S. Department of Commerce and the Commerce Control List (the “CCL”) therein, the International Traffic in Arms Regulations (ITAR) administered by the U.S. Department of State and the United States Munitions List (the “USML”) therein, as well as other U.S. export control regulations and laws, including the Embargo and Sanctions Regulations issued by the U.S. Department of the Treasury, Office of Foreign Assets Control (OFAC).

We must obtain certain information about your company and the intended end-use / end-user of these items, in order to comply with these various U.S. regulations.

To facilitate our proper export compliance and documentation, we require that your company provide a signed End-Use Statement regarding the end-use and end-users of the items that we send you. Please send any questions to operationsdepartment@emsintl.com

For Your Information: The end-user is defined as the ultimate consignee who will use or receive the item. (NOTE: This is not a distributor, freight forwarder, broker or shipping agent.) The end-use is defined as, “the final item that our products or information will be integrated into.” Some examples of end-use products can include aircraft, land vehicles, appliances, etc. We will keep this End-Use Statement on file for a period of two (2) years. If the end-user or end-use has changed, or if the two-year period has expired, you must complete and return to us a new End-Use Statement prior to the delivery of any future items or services.

END-USE FORM - Please Complete and Submit

We acknowledge that the export/re-export/re-transfer of commodities, software, and/or technical data (“Restricted Items”) that we have requested, purchased, or intend to purchase from EMSI, Inc. are subject to the U.S. export control laws and regulations, including, but not limited to, the Export Administration Regulations (“EAR”), the International Traffic in Arms Regulations (“ITAR”) and the Embargo and Sanction Regulations administered by the U.S. Department of the Treasury, Office of Foreign Assets Controls (“OFAC”), among other rules and regulations. We agree and undertake to comply with all applicable U.S. export control laws and regulations. Specifically, we make the following certifications and assurances:

We certify that we will not directly or indirectly export, re-export, transmit, or cause to be exported, re-exported or transmitted, any Restricted Item to any country, individual, corporation, organization, or entity to which such export, re-export, or transmission is restricted or prohibited.

Agree

We certify that we will use the export-controlled items listed below for (check one)

Note: Reviews of “civil end-use” must include both the activities of the end user as well as the end use of the items to be exported. The term “military end user” is not limited to traditional military end users such as army or navy but applies to any person or entity including private companies, universities and research institutes whose actions or functions are intended to support “military end uses.” Therefore, even if the export is for purely civil end uses, a license would be required if the end user is a “military end user.” *Military end use: Incorporation of an item into a military item controlled on the ITAR; incorporation of an item into items classified under military ECCNs; or any item that supports or contributes to the operation, installation, maintenance, repair, overhaul, refurbishing, ‘‘development,’’ or ‘‘production,’’ of military items either described on the USML or classified under military ECCNs. *Military end user: The national armed services (army, navy, marine, air force, or coast guard), as well as the national guard and national police, government intelligence or reconnaissance organizations, or any person or entity whose actions or functions are intended to support ‘military end uses’ as noted above.

Civil End-Use

Military End-Use

List P.O. Number or item designations

End-Use Application

We certify that we will not use items purchased from EMSI for any nuclear, biological or chemical weapons, or the missile systems that deliver them; for the design, development, production, testing, stockpiling or use of any weapons of mass destruction; or for any other use that the U.S. government prohibits.

Agree

We certify that we will immediately notify EMSI, Inc. if our company is, or becomes, listed in any Restricted Parties List, or if our export privileges are otherwise denied, suspended or revoked, in whole or in part, by any U.S. Government entity or agency.

Agree

We acknowledge that it is our responsibility to obtain any license for export/re-export of export-controlled Items, or to transmit information regarding Restricted Items, as may be required by U.S. export regulations and laws.

Agree

PROJECT INFORMATION

1. Project Name

2. Estimated Completion Date

3. Products Used

4. Estimated Number of Orders for Project

STATEMENT OF PURCHASER & ULTIMATE CONSIGNEE

We certify by signature that all of the facts contained in this statement are true and correct to the best of our knowledge and will apply to the disposition of products purchased from EMSI, Inc. We acknowledge the making of any false statements or concealment of any material fact in connection with this statement may result in denial, in whole or in part, of participation in U.S. exports and re-exports. The undersigned certify that we are responsible officials of our organizations and that we are authorized to sign this End-Use Statement on their behalf.

--Purchaser--

Company Name

Purchaser Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

*Digital Signature*

By filling this field, you authorize this signature to certify everything in this form to be true

Name (Authorized Company Representative)

First Name

Last Name

Job Title

Email Address

Date

YYYY

-- ULTIMATE CONSIGNEE --

This is the final recipient of the goods purchased

The Ultimate Consignee of these goods is:

Purchaser (same address as above)

Another address, person, or company

Ultimate Consignee Address, if different from Purchaser

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

*Digital Signature*

By filling this field, you authorize this signature to certify everything in this form to be true

Name (Authorized Company Representative)

First Name

Last Name

Job Title

Email Address

Date

YYYY

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EMSI INC.

Two Penn Center • 1500 JFK Boulevard - Suite 1930 • Philadelphia, PA 19102 - USA

T: +1 (215) 732 1900 | F: +1 (215) 732 7778

sales@emsintl.com