| To ensure all required fields have been
populated before submitting to your customers review form for any line items
highlighted in red |
Required fields remaining to be
completed |
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| Click here to
return to Declaration tab |
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| Required Fields |
Answer provided |
Notes |
Hyperlink to source |
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necessary? |
complete? |
incomplete |
comment1 |
comment for remaining |
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| Company Name (*): |
Metal Surfaces
International, LLC. |
Complete |
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1 |
0 |
0 |
Complete |
Provide your company name on the
Declaration tab cell D8 |
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| Declaration Scope or Class (*): |
A.
Company |
Complete |
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1 |
0 |
0 |
Complete |
Select the scope of declaration on
the Declaration tab cell D9 |
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| Description of Scope: |
Company-wide |
Complete |
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0 |
0 |
0 |
Complete |
Provide description of
scope on Declaration tab cell D10 |
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| Contact Name (*): |
Sam
Bell |
Complete |
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1 |
0 |
0 |
Complete |
Provide contact name in
Declaration tab cell D15 |
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| Email – Contact (*): |
sbell@metalsurfaces.com |
Complete |
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1 |
0 |
0 |
Complete |
Provide a valid email
for contact in Declaration tab cell D16 |
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| Phone – Contact (*): |
562-927-1331 |
Complete |
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1 |
0 |
0 |
Complete |
Provide a phone number
for contact in Declaration tab cell D17 |
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| Authorizer (*): |
Sam
Bell |
Complete |
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1 |
0 |
0 |
Complete |
Provide authorized
company representative contact name in Declaration tab cell D18 |
| Email - Authorizer (*): |
sbell@metalsurfaces.com |
Complete |
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1 |
0 |
0 |
Complete |
Provide an email for
authorized company representative on Declaration tab cell D20 |
| Effective Date (*): |
23-Jul-2024 |
Complete |
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1 |
0 |
0 |
Complete |
Provide date the form
was completed on Declaration tab cell D22 |
| 1)
Is any 3TG intentionally added or used in the product(s) or in the production
process? (*) |
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0 |
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| Tantalum |
No |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Tantalum is
intentionally added to your products on Declaration tab cell D26 |
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| Tin (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Tin is intentionally
added to your products on Declaration tab cell D27 |
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| Gold (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Gold is intentionally
added to your products on Declaration tab cell D28 |
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| Tungsten |
No |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Tungsten is
intentionally added to your products on Declaration tab cell D29 |
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| 2)
Does any 3TG remain in the product(s)? (*) |
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| Tantalum |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if Tantalum is necessary
to the production of your products and contained within the finished products
declared in Declaration tab cell D32 |
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| Tin (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Tin is necessary to the
production of your products and contained within the finished products
declared in Declaration tab cell D33 |
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| Gold (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Gold is necessary to
the production of your products and contained within the finished products
declared in Declaration tab cell D34 |
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| Tungsten |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if Tungsten is necessary
to the production of your products and contained within the finished products
declared in Declaration tab cell D35 |
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| 3)
Do any of the smelters in your supply chain source the 3TG from the covered
countries? (SEC term, see definitions tab) (*) |
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| Tantalum |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if Tantalum used
within the scope of products declared within this survey response originated from the DRC or an adjoining Country on the
Declaration tab cell D38 |
| Tin (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Tin used
within the scope of products declared within this survey response originated from the DRC or an adjoining Country
on the Declaration tab cell D39 |
| Gold (*) |
No |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Gold used
within the scope of products declared within this survey response originated from the DRC or an adjoining Country
on the Declaration tab cell D40 |
| Tungsten |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if Tungsten used
within the scope of products declared within this survey response originated from the DRC or an adjoining Country on the
Declaration tab cell D41 |
| 4)
Do any of the smelters in your supply chain source the 3TG from
conflict-affected and high-risk areas? (*) |
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| Tantalum |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if Tantalum used
within the scope of products declared within this survey response originated from a conflict-affected and high-risk area on
the Declaration tab cell D44 |
| Tin (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Tin used
within the scope of products declared within this survey response originated from a conflict-affected and
high-risk area on the Declaration tab cell D45 |
| Gold (*) |
No |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Gold used
within the scope of products declared within this survey response originated from a conflict-affected and
high-risk area on the Declaration tab cell D46 |
| Tungsten |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if Tungsten used
within the scope of products declared within this survey response originated from a conflict-affected and high-risk area on
the Declaration tab cell D47 |
| 5)
Does 100 percent of the 3TG (necessary to the functionality or production of
your products) originate from recycled or scrap sources? (*) |
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| Tantalum |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if Tantalum used within
the scope of products declared within this survey response originated
entirely from a recycled or scrap source on the Declaration tab cell D44 |
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| Tin (*) |
No |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Tin used within the
scope of products declared within this survey response originated entirely
from a recycled or scrap source on the Declaration tab cell D45 |
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| Gold (*) |
No |
Complete |
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1 |
0 |
0 |
Complete |
Declare if Gold used within the
scope of products declared within this survey response originated entirely
from a recycled or scrap source on the Declaration tab cell D46 |
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| Tungsten |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if Tungsten used within
the scope of products declared within this survey response originated
entirely from a recycled or scrap source on the Declaration tab cell D47 |
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| 6)
What percentage of relevant suppliers have provided a response to your supply
chain survey? (*) |
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| Tantalum |
0% |
Complete |
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0 |
1 |
0 |
Complete |
Provide % of
completeness of supplier's smelter information on Declaration tab cell D50 |
| Tin (*) |
100% |
Complete |
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1 |
0 |
0 |
Complete |
Provide % of
completeness of supplier's smelter information on Declaration tab cell D51 |
| Gold (*) |
100% |
Complete |
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1 |
0 |
0 |
Complete |
Provide % of
completeness of supplier's smelter information on Declaration tab cell D52 |
| Tungsten |
0% |
Complete |
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0 |
1 |
0 |
Complete |
Provide % of
completeness of supplier's smelter information on Declaration tab cell D53 |
| 7)
Have you identified all of the smelters supplying the 3TG to your supply
chain? (*) |
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| Tantalum |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if all smelter
names have been provided in this survey response under the scope of products declared on the Declaration tab cell D56 |
| Tin (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Declare if all smelter
names have been provided in this survey response under the scope of products declared on the Declaration tab cell D57 |
| Gold (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Declare if all smelter
names have been provided in this survey response under the scope of products declared on the Declaration tab cell D58 |
| Tungsten |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if all smelter
names have been provided in this survey response which the scope of products declared on the Declaration tab cell D59 |
| 8)
Has all applicable smelter information received by your company been reported
in this declaration? (*) |
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| Tantalum |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if all
applicable Tantalum smelter information has been provided on Declaration tab cell D62 |
| Tin (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Declare if all
applicable Tin smelter information has been provided on Declaration tab cell D63 |
| Gold (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Declare if all
applicable Gold smelter information has been provided on Declaration tab cell D64 |
| Tungsten |
0 |
Complete |
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0 |
1 |
0 |
Complete |
Declare if all
applicable Tungsten smelter information has been provided on Declaration tab cell D65 |
| Question |
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| A.
Have you established a responsible minerals sourcing policy? (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Answer if your company
has a responsible minerals sourcing policy on the Declaration tab cell D75 |
| B. Is
your responsible minerals sourcing policy publicly available on your website?
(Note – If yes, the user shall specify the URL in the comment field.) (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Answer if your company
has made your responsible minerals sourcing policy publically
available on your website on the Declaration tab cell D77 |
| The
URL in the comment field |
https://www.metalsurfaces.com/customer-service |
Complete |
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1 |
0 |
0 |
Complete |
Enter the URL in
Declaration worksheet cell G77 if you answer "Yes" for question B. The format of the URL should be
"www.companyname.com" |
| C. Do
you require your direct suppliers to source the 3TG from smelters whose due
diligence practices have been validated by an independent third party audit
program? (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Answer if you require
your direct suppliers to source from smelters whose due diligence practices have been validated by an independent third-party
audit program, like the Responsible Minerals Assurance Process, on
Declaration tab cell D79 |
| D.
Have you implemented due diligence measures for responsible sourcing? (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Answer if you have
implemented due diligence measures for responsible sourcing on Declaration tab cell D81 |
| E.
Does your company conduct Conflict Minerals survey(s) of your relevant
supplier(s)? (*) |
Yes,
in conformance with IPC1755 (e.g., CMRT) |
Complete |
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1 |
0 |
0 |
Complete |
Answer if you request
your suppliers to fill out this Conflict Minerals Reporting Template on Declaration tab cell D83 |
| F. Do
you review due diligence information received from your suppliers against
your company’s expectations? (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Answer if you verify
responses from your suppliers against your company's expectations on Declaration tab cell D85 |
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| G.
Does your review process include corrective action management? (*) |
Yes |
Complete |
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1 |
0 |
0 |
Complete |
Answer if your
verification process includes corrective action management on Declaration tab cell D87 |
| H. Is
your company required to file an annual conflict minerals disclosure? (*) |
No |
Complete |
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1 |
0 |
0 |
Complete |
Answer if you are
subject to the SEC Disclosure requirement, the EU regulation or both on Declaration tab cell D89 |
| Product
List |
No
products or item numbers listed |
Complete |
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0 |
1 |
0 |
Complete |
If applicable, provide 1
or more Products or Item Numbers this declaration applies
to. From Declaration tab select hyperlink in cell 6H1 to enter Product List
tab |
| Smelter
List - Tantalum |
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Complete |
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0 |
1 |
0 |
Complete |
Provide list of tantalum smelters
contributing material to supply chain on Smelter List tab |
0 |
#N/A |
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| Smelter
List - Tin |
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Complete |
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1 |
0 |
0 |
Complete |
Provide list of tin smelters
contributing material to supply chain on Smelter List tab |
0 |
#N/A |
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| Smelter
List - Gold |
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Complete |
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1 |
0 |
0 |
Complete |
Provide list of gold smelters
contributing material to supply chain on Smelter List tab |
0 |
#N/A |
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| Smelter
List - Tungsten |
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Complete |
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0 |
1 |
0 |
Complete |
Provide list of tungsten smelters
contributing material to supply chain on Smelter List tab |
0 |
#N/A |
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| All
rows with "Smelter not listed" selected, have a name and country
listed |
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N/A |
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0 |
0 |
0 |
Complete |
N/A |
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Please complete columns
D & E on Smelter List for all rows
"Smelter Not Listed" selected in column C |
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