<p> UTMB RECORD OF EXPORT CONTROL REVIEW FORM For Material Transfer Agreements</p><p>Name of UTMB Faculty Member (Providing Scientist): Date: </p><p>Technical Review: (To be completed by the Recipient Scientist)</p><p>Please provide complete information of the Receiving Party:</p><p>Name: </p><p>Address: </p><p>US Citizenship/visa status / nationality of the Receiving Party: </p><p>State the specific name of material requested (e.g. West Nile Virus). Please clarify if material is a cellular component or the complete organism. </p><p>Yes No</p><p>Does this material contain infectious biological materials? </p><p>Is this material composed only of vaccines and immunotoxins? </p><p>Will your receipt and use of this Material involve requests for information that is not publicly available to be answered by UTMB Faculty Member? </p><p>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? </p><p>Does this transfer require the delivery of hardware, software, materials or biological materials to a non U.S. citizen? </p><p>By signing below, I certify that I have read this document and completed the appropriate sections to the best of my knowledge and belief:</p><p>______Recipient scientist signature Date</p><p>Please return completed form by fax, scan, or mail to:</p><p>Office of Technology Transfer 301 University Boulevard Galveston, Texas 77555-0926 Fax: (409) 772-7954</p><p>If you have questions, contact Frances R. Streeter, J.D.-Office of Technology Transfer, (409) 772-0376, [email protected].</p><p>UTMB Export Control Form</p>