Self-Certification Form for Temporary Export of Encryption Software
[ ] I certify that:
- I am a U.S. citizen or lawful permanent resident (green card holder);
- I complied with the conditions for use of the personal use exemption for temporary export of encryption products as published at 22 Code of Federal Regulations 123.27 and summarized above; and
- I have no reason to believe that any of the temporarily exported cryptographic products listed below were stolen, lost, copied, sold, or otherwise compromised or transferred while abroad. Products containing encryption software: Microsoft Internet Explorer 3.0 128-bit version I entered and departed the following countries on the following dates (include the United States): Country (List All) Date Entered Date Departed
Products containing encryption software:
Microsoft Exchange, North American version
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I entered and departed the following countries on the following dates (include the U.S.):
Country (List All) | Date Entered | Date Departed |
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Signature: ____________________________________
Name: ____________________________________
Date: __________________