Non-Exclusive License and Materials Transfer Agreement

UTMB RECORD OF EXPORT CONTROL REVIEW FORM For Material Transfer Agreements

Name of UTMB Faculty Member (Providing Scientist): Date:

Technical Review: (To be completed by the Recipient Scientist)

Please provide complete information of the Receiving Party:

Address:

US Citizenship/visa status / nationality of the Receiving Party:

State the specific name of material requested (e.g. West Nile Virus). Please clarify if material is a cellular component or the complete organism.

Yes No

Does this material contain infectious biological materials?

Is this material composed only of vaccines and immunotoxins?

Will your receipt and use of this Material involve requests for information that is not publicly available to be answered by UTMB Faculty Member?

Will your use of this Material involve research information or software that could be used in the development of weapons of mass destruction (nuclear, biological, chemical), or their delivery systems?

Does this transfer require the delivery of hardware, software, materials or biological materials to a non U.S. citizen?

By signing below, I certify that I have read this document and completed the appropriate sections to the best of my knowledge and belief:

______Recipient scientist signature Date

Please return completed form by fax, scan, or mail to:

Office of Technology Transfer 301 University Boulevard Galveston, Texas 77555-0926 Fax: (409) 772-7954

If you have questions, contact Frances R. Streeter, J.D.-Office of Technology Transfer, (409) 772-0376, [email protected].

UTMB Export Control Form