Request for Quote

All new customers are required to complete a visual compliance screening before we can proceed with a quotation. This form is required because it ensures we meet regulatory and compliance standards. Thank you in advance for your time.

1. Buyer’s Information
If an entity, include both legal entity name and any name used in doing business.
This field is required.
This field is required.
Buyer’s Address
Provide the full address of the buyer.
This field is required.
This field is required.
This field is required.
This field is required.
This field is required.
This field is required.
Indicate the nature of the buyer’s business.
This field is required.
Provide the buyer’s website URL.
This field is required.
Name of the person we should contact.
This field is required.
Provide a contact phone number.
This field is required.
2. Ultimate Consignee’s Information
If an entity, include both legal entity name and any name used in doing business.
This field is required.
Buyer’s Address
Provide the full address of the buyer.
This field is required.
This field is required.
This field is required.
This field is required.
This field is required.
This field is required.
Indicate the nature of the consignee’s business.
This field is required.
Provide the consignee’s website URL.
This field is required.
3. Ultimate Product Application
(By Buyer Or Ultimate Consignee)
Will the microdisplay be incorporated into a military product? If yes, please describe.
This field is required.
This field is required.
E.g., night vision
This field is required.
This field is required.
This field is required.
This field is required.
This field is required.
Buyer certifies that all of the facts stated in this questionnaire are true and correct and that it does not know of any additional facts that are inconsistent with the above statements.

Buyer shall promptly send a replacement certification to eMagin disclosing any material change of facts or intentions described herein after the date of signature. eMagin reserves the right to refuse to conduct business with parties who fail to certify the foregoing, who certify false information, or who fail to promptly send a replacement certification when required.

Misrepresentations regarding the information herein may result in termination of any applicable warranties or related services.

Buyer covenants to comply with all applicable export controls and economic sanctions and agrees not to use, export, reexport, or resell the OLED Microdisplay for any purpose or to any end user contrary to the representations made in this certification.

Failure to comply with this covenant shall constitute a breach of Buyer’s purchase agreement with eMagin.
This field is required.
Buyer certifies that, to the best of its knowledge, the anticipated disposition, use, and consignee of the purchased product are permitted under and consistent with the U.S. Export Administration Regulations (15 CFR Parts 730-774), the International Traffic in Arms Regulations (22 CFR Parts 120-130), and trade sanctions administered by the Office of Foreign Assets Control.

Buyer agrees not to re-export or resell the purchased products for any purpose to Russia, East Ukraine region, North Korea, Iran, Syria, Cuba, and Venezuela.
This field is required.
This field is required.
Save Progress Saves your current progress and provides a link to resume later.