Export Control Determination Request

Date Submitted
MM slash DD slash YYYY
Ship Date
MM slash DD slash YYYY
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?
Phone
This field is for validation purposes and should be left unchanged.

Requested By: