Shipment: ______

(Administrative Only)

Request to Ship/Carry Equipment/MaterialsInternationally

Excludes Personal Shipments

Equipment and materials may NOT be sent or carried outside of the U.S.until it is determined whether an export license or other authorization is required. The information on this form is used to make export licensing determinations. Therequest should be submitted to the Export Control Officer as far in advance of shipping date as possible, as it can take on average 3 months to obtain a license, if required. Until you receive notification of approval from Export Control Officer, NO materials may be transferred/carried to a foreign destination. For more information,seethe UCI Export Controls Guidelines at http://www.research.uci.edu/compliance/export-controls/exporter/international-shipping.html.

A.UCI Contact Information

PI Name: Department:
Phone: Cell No: Email:
TechnicalContact Name:
Phone: Email:

B. Method of Shipment

Will a traveler take the equipment/materials as baggage? Yes No
If yes:
Indicate their name and affiliation:
Indicate how equipment/material will be transported: Carry On or Checked Baggage
Dates of travel:
Carrier and flight number(s):
Will the items return to the U.S. with the traveler? Yes No
Will the equipment/materials be shipped? Yes No
If yes:
Date needed in destination country: Preferred shipment deadline:
Method of shipment (check one):
FEDEX UPS DHL ACS Stevens Global Logistics Other:
Estimated weight of shipment:
Will the equipment/materials be returned to the U.S.? Yes No
If Yes, which specific items? When?
How?

C. Destination Information

Name of Recipient:
Recipient Institution:
Physical Address:
Country:
What is the purpose of the shipment?
Research Collaboration Return to Manufacturer for Repair Equipment Loan
Material Transfer Agreement Sale of Equipment Other:
Will the end-user be involved in any of the following activities or industries?
Nuclear or Atomic (i.e. power plants, nuclear facilities, etc.)
Chemical or Biological (i.e. chemical plants, petroleum, etc.)
Will foreign national end users be trained on how to use the equipment/materials?
Yes No Explain:

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Shipment: ______

(Administrative Only)

D. Equipment/Material to be Shipped

Common and Technical Name / UCI Built*
or
1. Manufacturer
2. Model/Serial Number(s)
3. URL or attach copy of specifications / General function and use / Number of Items Shipped / Total US dollar value (Same as insured value) / Is this item typically required to carry out your professional activities? / Is the item toxic, hazardous, pathogenic, or an attenuated biological agent? / Is the item a Spacecraft System or associated equipment?** / Is the item designed or adapted for Military Application? / Does the item contain encrypted software or firmware?
1 / UCI Built*
1.
2.
3. / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
2 / UCI Built*
1.
2.
3. / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
3 / UCI Built*
1.
2.
3. / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
4 / UCI Built*
1.
2.
3. / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
5 / UCI Built*
1.
2.
3. / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
6 / UCI Built*
1.
2.
3. / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No

*If UCI built, please provide technical specifications (i.e., powerpoint, published papers, poster, etc.).

**Spacecraft System or associated equipment also includes specifically designed components, parts, accessories, or attachments including scientific or research payloads.

Submit the Request to .

Questions? Contact Marci Copeland, Export Control Officer, or 949-824-0445

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