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Deemed Export Attestation Application Form
Please follow the instructions to submit the application form
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Print and fill out the form (complete pages 1, 2 and 3)
Have the form signed in blue ink and dated
Scan the document as a pdf file to your computer, and
Email the completed form to ejmcginty@pvamu.edu along with the Position Description, and
Comments to Question 3. (if, applicable)
Note: Incomplete Applications will not be processed.
Document will be reviewed by:
HUMAN RESOURCES IMMIGRATION SERVICES OFFICE
Mrs. Evelyn McGinty
Immigration Services Associate
Harrington Science Bldg. Room 107D
Email: ejmcginty@pvamu.edu
Phone: (936) 261-1725
NOTE: Label any Attachments “Deemed Export – (Applicant’s Name)”
You are certifying that technology or technical data you will release or otherwise provide access to
the foreign national as a result of the offered employment may or may not require a license. This
certification will be made available to the federal authorities in case of a request or audit.
DEEMED EXPORT CONTROL ATTESTATION – SIGNATURE PAGE
Note: Provide all signatures in blue ink and return to Human Resources - Immigration Services.
1. My full name is:
2. I am the Dean/Director, Department Head, Principal Investigator:
3. In the department of:
4. The PVAMU College of, or Administrative Unit:
Contact Information:
5. Email:
6. Office Telephone Number:
7. Physical address:
_____________________________________________________________________________
_____________________________________________________________________________
I have knowledge of:
8. The proposed employment of (applicant):
EXP-C ATT EMPLOYER 15.1 REVISED April 25, 2014
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9. Title/Position:
10. A description of the position responsibilities and duties for which a nonimmigrant petition
is being sought is attached* (i.e. position description with associated title and number).
NOTE: *Label the attachment as: DEEMED EXPORT– APPLICANT’s NAME.
11. I have reviewed the duties and responsibilities for said employment and I have
knowledge of the type of technology and/or technical data that will be released to the
employee. In this regard, I hereby certify the following:
12. With respect to the technology or technical data that I will release, or otherwise provide
access to (name of the foreign person proposed employee or employee):
13. As a result of the employment, I certify that:
Initial
I have reviewed the Export Administration Regulations (EAR) and the International
Traffic in Arms Regulations (ITAR) with regard to such technology or technical data; or
I have reviewed the Export Administration Regulations (EAR) and the International
Traffic in Arms Regulations (ITAR) and thereafter have contacted the Research Compliance
Office at Prairie View A&M University to further clarify potential restrictions regarding such
technology or technical data and, I have determined that for prospective employee that for
the position duties:
13.1
A license is not required from either the U.S. Department of Commerce or the U.S.
Department of State to release such technology or technical data to the above named foreign
person; or
13.2
A license is required from the U.S. Department of Commerce and/or the U.S.
Department of State to release such technology or technical data to the foreign
person and I will prevent access to the controlled technology or technical data by
the named foreign person until and unless Prairie View A&M University has
received the required license or other authorization to release it to the named
foreign person.
If the response to questions 13.1. or 13.2. is ‘YES’ or ‘UNKNOWN’. Provide details under a
separate attachment. Label the attachment as: DEEMED EXPORT – APPLICANT’s NAME.
EXP-C ATT EMPLOYER 15.1 REVISED April 25, 2014
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RETURN to ATTESTATION SIGNATURE PAGE:
I hereby certify under penalty of perjury that the foregoing is true and correct to the best of my
knowledge.
1. Principal Investigator/Employee:
__________________________________
Printed Name
2.
_______________________________
Position/Title -Program
Signature & Date
Department Head or Director
__________________________________
Printed Name
_______________________________
Department Head or Director: (circle one)
Signature & Date
3. Dean or Vice President: (circle one)
_________________________________
Printed Name
_______________________________
College/ Unit
EXP-C ATT EMPLOYER 15.1 REVISED April 25, 2014
Signature & Date
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INTERNAL REVIEW ONLY
Restricted Party Screening – Immigration Services Associate
Employee Name:
Birthdate:
Gender:
Male:
Female:
Result
Date Initial Screening was Performed:
Is Secondary Screening is Required – if so
Date Screening was Performed:____________
Name and Title of Initial Screener:
Name:
Mrs. Evelyn McGinty
Signature: _____________________________
Title: Immigration Services Associate
Date: _________________________
Name and Title of Secondary Screener:
Name:
Dr. Marcia C. Shelton
Signature :
Title: Export Controls Officer
Date:
EXP-C ATT EMPLOYER 15.1 REVISED April 25, 2014
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INTERNAL REVIEW ONLY
DEEMED EXPORT CONTROL DETERMINATION – TO BE COMPLETED BY Export Controls Officer I have determined that:
1. A license is not required from either the U.S. Department of Commerce or the U.S. Department of State to release
such technology or technical data to the above named foreign person; or
2. A license is required from the U.S. Department of Commerce and/or the U.S. Department of State to release such
technology or technical data to the foreign person and I will prevent access to the controlled technology or technical
data by the named foreign person until and unless Prairie View A&M University has received the required license or
other authorization to release it to the named foreign person.
I hereby certify under penalty of perjury that the foregoing is true and correct to the best of my knowledge.
Export Controls Officer:
Marcia C. Shelton, PhD
_________________________________
Printed Name
_______________________________
Signature & Date
EXP-C ATT EMPLOYER 15.1 REVISED April 25, 2014