Conflict Minerals Declaration Document
Company Information
Company Name:
Address:
Contact Person:
Title:
Email:
Phone:
Declaration
We, the undersigned, hereby declare that the products we supply to our customers are:
| Product/Part Number |
Description |
Contains 3TG* (Yes/No) |
Country of Origin |
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* 3TG refers to Tin, Tantalum, Tungsten, and Gold as defined in the Dodd-Frank Wall Street Reform and Consumer Protection Act (Section 1502).
Due Diligence and Source Verification Process
Statement
Authorized Signature:
Name:
Title:
Date: