ࡱ> ]_\M &bjbj== "RWW9 ltttt8\z<l. . . . t DM$  s " tt. . Et8. . :,.  Gn 0RH!VH!tttt91ɫƬ Request to Ship Materials or Equipment Outside the U.S. Equipment and materials may not be sent outside the U.S. or used by a foreign person until UMD determines whether an export control license, loan, or other agreement is required. The information provided on this form is used to help make those determinations. Sections A, B, and C must be completed by the PI. Complete a separate form for each separate item and transaction. Submit the request as far in advance of the preferred shipping date as it can take up to 6 months to obtain a license, if one is required. Until approval is received, no materials are allowed to be transferred to a foreign destination or a foreign national. For more information, refer to the UMD Export Controls Guidelines at  HYPERLINK "http://www.umassd.edu/grants_contracts/compliance/main.cfm" http://www.umassd.edu/grants_contracts/compliance/main.cfm under Export Controls. A. UMD Contact and Contract Information PI Name: FORMTEXT      Office Ext: Fax: Email:  FORMTEXT        FORMTEXT        FORMTEXT      Department: FORMTEXT      Mailing Address: FORMTEXT      Name of Department Contact: FORMTEXT      Email Office Ext FORMTEXT        FORMTEXT       Information about Equipment/Materials 1. Common Name: FORMTEXT       2. Technical Name: FORMTEXT       3. Manufacturer, Model No.: FORMTEXT       4. General Function and Use: FORMTEXT       5. U.S. Dollar Value of Material to be Transferred: FORMTEXT       6. Amount of Material to be Transferred: FORMTEXT       7. URL where specifications may be found: FORMTEXT       Or  FORMCHECKBOX  check if hard copies of specifications are being sent and list documents sent here.  FORMTEXT       8. If an entity other than UMD owns title in the equipment/materials, identify that entity: FORMTEXT       9. Classification of materials  FORMCHECKBOX  DNA or human genes  FORMCHECKBOX  Bloodborne pathogen  FORMCHECKBOX  Infectious material  FORMCHECKBOX  Virus  FORMCHECKBOX  Select agent  FORMCHECKBOX  Chemicals  FORMCHECKBOX  Hazardous material  FORMCHECKBOX  Other, explain: FORMTEXT       10. Is the sample or material in the public domain (can anyone purchase it commercially without restrictions)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11. Is the item a defense article (or component, or part thereof); technical data used for design development, assembly, production, operation, repair, testing maintenance, or modification of a defense article; or a defense service to provide assistance, including training, to a foreign person in the U.S. or abroad in the design, manufacture, repair, or operation of a defense article, as well as providing military training or advice to foreign military forces? Note: Technical data may include drawings or instructions, operations and maintenance manuals, as well as email or telephone conversations that discuss tech data. Defense services may include informal collaborations, conversations, or interchanges concerning technical data.  FORMCHECKBOX  Yes  FORMCHECKBOX  No Information about Purpose and Recipient (End User and End Use) 1. Name of Intended Recipient: FORMTEXT       Recipient Institution: FORMTEXT       Address(P.O. box is not acceptable): FORMTEXT       Country:  FORMTEXT       Phone No.: FORMTEXT       Fax No.: FORMTEXT       Email: FORMTEXT       Birth Date of Recipient: FORMTEXT       Place and Country of Birth of Recipient: FORMTEXT       2. Intended Use of Equipment/Materials by Recipient:  FORMTEXT       3. Will UMD train foreign national end users how to use the equipment/materials?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Explain: FORMTEXT       4. Will the Equipment/Materials be  on Loan to the Recipient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, what is the loan period?  FORMTEXT       If no, do you intend to transfer title in the equipment/materials to the recipient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Other disposition of equipment/materials? Explain: FORMTEXT       5. Preferred deadline for shipping equipment/materials: FORMTEXT       6. Is there a letter of engagement on file from the freight forwarder?  FORMCHECKBOX  Yes  FORMCHECKBOX  No D. Submit the Request to Joanne Zanella-Litke at  HYPERLINK "mailto:jzanella@umassd.edu" jzanella@umassd.edu .  E. Export Recommendation (this section completed by Office of Research Compliance): 1. Is the equipment/material controlled under the ITAR?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, identify the USML category: FORMTEXT       License is required. 2. Is the equipment material controlled under the EAR?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, identify the ECCN: FORMTEXT       Is a license required?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Explain: FORMTEXT       3. Do you recommend filing a commodity jurisdiction request with State?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4. Do you recommend filing a commodity classification request with Commerce?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. Is the receiving and/or any end users identified on the Denied Persons List, Unverified List, Entity List, Specially Designated Nationals List, Debarred List or subject to an OFAC boycott?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, explain: FORMTEXT        FORMCHECKBOX  Approved, Initial and Date:  FORMTEXT           KgjZWX &@FH\^lnpĹĹĹĎĹ|ĎĹjĎ#jLCJOJQJU^JaJ#jCJOJQJU^JaJ OJQJ^J#jxCJOJQJU^JaJ#jCJOJQJU^JaJCJOJQJ^JaJjCJOJQJU^JaJCJ 0JCJaJjCJUaJ >*CJaJ 6CJaJ 5CJaJCJaJ5)JK&4Fn$If $If] `'`$If]`$If&&& " SI;+ 4`'H$If]H `'`$If]` `'$If$$IfTl\~L D ( @  0'4 la " $ 8 : H J L    " n ߮ߜƗmk5#jzCJOJQJU^JaJ#jCJOJQJU^JaJ 5CJaJCJaJ#jCJOJQJU^JaJ#j.CJOJQJU^JaJ 5@CJ OJQJ^J#jCJOJQJU^JaJCJOJQJ^JaJjCJOJQJU^JaJ5CJCJ&" J L E5/ $If 4`'H$If]H$$IfTl\~L D ( @  0'4 la `'`$If]`  " ?=$$IfTl\~L D ( @  0'4 la `'`$If]`$If" n ^ N @ :XD,JX` `'^ & F h0`0 6 8 L N \ & ( < > L   . μΪΘΆ}q}b}jCJUaJmHnHujJCJUaJjCJUaJ#jCJOJQJU^JaJ#jZCJOJQJU^JaJ#jCJOJQJU^JaJ#jjCJOJQJU^JaJCJOJQJ^JaJCJaJjCJOJQJU^JaJ#jCJOJQJU^JaJ . 0 > F H d f h (*8Z\xz|FHdfh޹޹ى}qej CJUaJj CJUaJj CJUaJjCJUaJ#j&CJOJQJU^JaJ#jCJOJQJU^JaJCJOJQJ^JaJj:CJUaJjCJUaJCJaJjCJOJQJU^JaJ#jCJOJQJU^JaJ'hz|"$&NPlnpUVdefop~uv~rj CJUaJj2 CJUaJj CJUaJ#jD CJOJQJU^JaJCJOJQJ^JaJjCJOJQJU^JaJj CJUaJjX CJUaJj CJUaJjn CJUaJjCJUaJCJaJ+*,rt"$8:H^`tvɷɥɓɁo]#jCJOJQJU^JaJ#jtCJOJQJU^JaJ#jCJOJQJU^JaJ#jCJOJQJU^JaJ#j CJOJQJU^JaJ#jCJOJQJU^JaJCJOJQJ^JaJjCJOJQJU^JaJ5CJaJjCJUaJjCJUaJ$$&:<J.0DFT,.JLNhj~.xf#j,CJOJQJU^JaJjCJUaJjDCJUaJjCJUaJ#jCJOJQJU^JaJ#jTCJOJQJU^JaJ#jCJOJQJU^JaJ#jdCJOJQJU^JaJCJOJQJ^JaJjCJOJQJU^JaJCJaJ&XVjjN > !f!!0"# $$&&&&&&&.02@B^`bBDXZhUVdefmʿʿʿqʿejCJUaJ#jdCJOJQJU^JaJ#jCJOJQJU^JaJjxCJUaJjCJUaJ#jCJOJQJU^JaJCJOJQJ^JaJjCJOJQJU^JaJjCJUaJCJaJjCJUaJjCJUaJ'mn|}~I  > sj$CJUaJ#jCJOJQJU^JaJCJOJQJ^JaJjCJOJQJU^JaJj8CJUaJjCJUaJ 6CJaJjCJUaJmHnHu 0JCJaJ 5CJaJjPCJUaJCJaJjCJUaJ, !>!@!T!V!d!!!!!!!!!!!" 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