Company Name *

Declaration scope or Class *
—Veuillez choisir une option—A. CompanyB. Product (or List of products)C. User defined
Company Address *

Authorizer (name of the person in charge of Conflict Minerals activities) *

Authorizer (First name of the person in charge of Conflict Minerals activities *

Title of Authorizer *

Phone of Authorizer *

Email of Authorizer *

Effective Date *

ANSWERING THE FOLLOWING QUESTIONS IS MANDATORY TO YOUR COMPANY:

Question 1: Is any 3TG intentionally added or used in the product(s) or in the production process?

Tantalum (required)
YESNO
Comments

Tin (required)
YESNO
Comments

Gold (required)
YESNO
Comments

Tungsten (required)
YESNO
Comments

Question 2: Does any 3TG remain in the product(s)?

Tantalum (required)
YESNO
Comments

Tin (required)
YESNO
Comments

Gold (required)
YESNO
Comments

Tungsten (required)
YESNO
Comments

Therefore please add your company name in the following sentence :
certifies the accuracy of the present declaration.
We would like to inform you that the data in this form may be used by our services to respond to your request.
By checking this box, I accept that the data entered in this form will be used by BASSETTI DATA PROVIDER to contact me in the context of the commercial relationship that may result.
* Mandatory fields