Request to Ship/Carry Equipment/Materials Internationally Excludes Personal Shipments

advertisement
Shipment: __________________
(Administrative Only)
Request to Ship/Carry Equipment/Materials Internationally
Excludes Personal Shipments
Equipment and materials may NOT be sent or carried outside of the U.S. until it is determined whether an export license or other
authorization is required. The information on this form is used to make export licensing determinations. The request should be
submitted to the Export Control Officer as far in advance of shipping date as possible, as it can take on average 3 months to obtain a
license, if required. Until you receive notification of approval from Export Control Officer, NO materials may be transferred/carried to
a foreign destination. For more information, see the UCI Export Controls Guidelines at
http://www.research.uci.edu/compliance/export-controls/exporter/international-shipping.html.
A. UCI Contact Information
PI Name:
Phone:
Department:
Cell No:
Email:
Technical Contact Name:
Phone:
Email:
B. Method of Shipment
Will a traveler take the equipment/materials as baggage?
Yes
No
If yes:
Indicate their name and affiliation:
Indicate how equipment/material will be transported:
Carry On or
Checked Baggage
Dates of travel:
Carrier and flight number(s):
Will the items return to the U.S. with the traveler?
Yes
No
Will the equipment/materials be shipped?
Yes
No
If yes:
Date needed in destination country:
Preferred shipment deadline:
Method of shipment (check one):
FEDEX
UPS
DHL
ACS
Stevens Global Logistics
Other:
Estimated weight of shipment:
Will the equipment/materials be returned to the U.S.?
Yes
No
If Yes, which specific items?
When?
How?
C. Destination Information
Name of Recipient:
Recipient Institution:
Physical Address:
Country:
What is the purpose of the shipment?
Research Collaboration
Return to Manufacturer for Repair
Material Transfer Agreement
Sale of Equipment
Will the end-user be involved in any of the following activities or industries?
Nuclear or Atomic (i.e. power plants, nuclear facilities, etc.)
Chemical or Biological (i.e. chemical plants, petroleum, etc.)
Will foreign national end users be trained on how to use the equipment/materials?
Yes
No
Explain:
Page 1 of 2
Equipment Loan
Other:
Shipment: __________________
(Administrative Only)
D. Equipment / Material to be Shipped
Common and
Technical Name
UCI Built*
or
1. Manufacturer
2. Model/Serial Number(s)
3. URL or attach copy of
specifications
1
General function and use
Number
of Items
Shipped
Yes
No
Yes
No
Yes
No
UCI Built*
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
UCI Built*
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
UCI Built*
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
UCI Built*
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1.
2.
3.
5
Is the item
designed or
adapted for
Military
Application?
Does the
item
contain
encrypted
software
or
firmware?
Yes
No
1.
2.
3.
4
Is the item
a
Spacecraft
System or
associated
equipment
?**
Yes
No
1.
2.
3.
3
Is the item
toxic,
hazardous,
pathogenic,
or an
attenuated
biological
agent?
UCI Built*
1.
2.
3.
2
Total US
dollar
value
(Same as
insured
value)
Is this item
typically
required to
carry out
your
professional
activities?
1.
2.
3.
6
UCI Built*
Yes
Yes
Yes
Yes
Yes
1.
No
No
No
No
No
2.
3.
*If UCI built, please provide technical specifications (i.e., powerpoint, published papers, poster, etc.).
**Spacecraft System or associated equipment also includes specifically designed components, parts, accessories, or attachments including scientific or research payloads.
Submit the Request to [email protected]
Questions? Contact Marci Copeland, Export Control Officer, [email protected] or 949-824-0445
Page 2 of 2
Download