Export Control Determination Request

Company

This field is for validation purposes and should be left unchanged.

Date Submitted

Ship Date

Requested By:

Name*

First Last

Department/Unit

Phone

Email*

Department Administrator Responsible for Shipping Oversight:

Name

First Last

Email

Items Will be Shipped To:

Individual Name

First Last

Email

Entity Name

Street Address

City

State/Province

Country*

Is this exchange under an active Sponsored Project, Material Transfer Agreement, or Collaborative Research Agreement?*

Yes
No

Please provide details.

Provide RADAR or Applicable Agreement ID Number

Item Details

List all items to be shipped

Provide a detailed description of the item. (Depending on the item, characteristics may include brand, model number, software version, quantity, material properties, electrical properties,dimensions, concentration, etc.). Provide the cash value of each item.

For what purpose(s) are the items being shipped?

What will be the disposition of the items being shipped?

(Returned to US in X months, used and disposed of overseas)

Will the items being shipped be used in other countries? If so, where?

Requested By:

Department Administrator Responsible for Shipping Oversight:

Items Will be Shipped To:

Item Details

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