Request to Ship/Carry Equipment/Materials Internationally

Shipment: ______(Administrative Only) Request to Ship/Carry Equipment/Materials Internationally 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. The request 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, see the 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: Technical Contact 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? Page 1 of 4 Shipment: ______(Administrative Only)

Yes No Explain:

of 4 Shipment: ______(Administrative Only)

D. Equipment / Material to be Shipped UCI Built* or 1. Manufacturer Is the item 2. Is this item toxic, Model/Serial typically hazardous, Is the item a Is the item Does the item Number(s) required to pathogenic, or Spacecraft designed or contain Common and 3. URL or General Total US dollar carry out your an attenuated System or adapted for encrypted Technical attach copy of function and Number of value (Same as professional biological associated Military software or Name specifications use Items Shipped insured value) activities? agent? equipment?** Application? firmware? 1 UCI Built* Yes Yes Yes Yes Yes 1. No No No No No 2. 3. 2 UCI Built* Yes Yes Yes Yes Yes 1. No No No No No 2. 3. 3 UCI Built* Yes Yes Yes Yes Yes 1. No No No No No 2. 3. 4 UCI Built* Yes Yes Yes Yes Yes 1. No No No No No 2. 3. 5 UCI Built* Yes Yes Yes Yes Yes 1. No No No No No 2. 3. 6 UCI Built* Yes Yes Yes Yes Yes 1. No No No No No 2. 3. *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 [email protected]. Page 3 of 4 Shipment: ______(Administrative Only) Questions? Contact Marci Copeland, Export Control Officer, [email protected] or 949-824-0445