Document 10678876

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UNIVERSITY OF CALIFORNIA, IRVINE
OFFICE OF RESEARCH
REQUEST FOR EXPORT CONTROL REVIEW OF INTERNATIONAL SHIPMENTS
This information will help your campus Export Control Administrator determine whether or not an export license or other type of permit is
required for your shipment. It will also ensure that your shipment meets United States Federal government requirements including inspection
of your shipment and documentation by US and foreign customs officials.
Please submit the completed form to Marci Copeland ([email protected]).
1. UNIVERSITY REQUESTER
1.UCI
UNIVERSITY
REQUESTER NAME:
– UCI PRINCIPAL INVESTIGATOR
PRINCIPAL INVESTIGATOR
NAME:
DEPARTMENT/DIVISION:
DEPARTMENR/DIVISION:
PROJECT NAME:
PROJECT
NAME:
PROPOSAL
NUMBER (if available):
PROPOSAL NUMBER (IF AVAIALBLE):
TECHNICAL CONTACT:
TECHNICAL CONTACT:
PHONE:
PHONE:
EMAIL:
EMAIL:
EH&S CONTACT INFORMATION (IF INVOLVED):
2. SHIPMENT INFORMATION
☐ Yes
Were the materials built at UCI?
☐ No
yes, please provide
the following
information.
2.IfTECHNICAL
CONTACT
FOR THE
RECIPIENT
of Components:
1.List
SUBRECIPIENT
CAMPUS:
Manufacture Information:
3. SUBRECIPIENT PI DEPARTMENT:
If no, please provide the following information.
Manufacturer:
Is this a temporary or a permanent export?
2. SUBRECIPIENT PI:
Part/Serial No.:
Part/Serial No.:
☐ Temporary
☐ Permanent
Are the items designed or adapted for Military Application?
☐ Yes
☐ No
Does the item contain encrypted software or firmware?
☐ Yes
☐ No
If yes, please indicate the level of encryption.
Desired Shipping Date:
Please provide a brief description of the material (including applicable characteristics such as quantity, speed of equipment).
3. RECIPIENT INFORMATION
NAME:
COMPANY/INSTITUTION NAME:
HAZARDOUS MATERIAL:
☐ Yes ☐ No
ADDRESS:
COUNTRY:
OR- May 2013
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