Application for review

Of export-controlled activities

Name of exporter
First Last
Phone number
E-mail address
Department
Campus
Mail stop
Use this form to request an export review for any of these potentially export-controlled activities: Sharing, shipping, transmitting, or transferring to a foreign national in the U.S. or to a foreign individual/entity or country outside of the U.S. any of the following:
- goods (testing kits, equipment, hardware, and materials—including biological materials)
- technology (technical information and data)
- software/codes (commercial or custom)
1. Item to be exported
What item will you be exporting?
- Good
- Technology
- Software
Item name
Make and model #
Company/source name
Company/source phone
Item order number (if available)
Include or attach technical information
Max. file size: 80 MB.
2. Recipient
To whom is the item being shipped?
- Company
- Individual
Recipient name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
3. Additional users/recipients
Will the item be used by or shipped to others?
- Yes
- No
If yes, please provide the following information:
Who else will use or receive the item?
- Company
- Individual
Additional user/recipient name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
4. Third party (freight forwarder) used for export
Will the item be exported through a third party (i.e. freight forwarder)?
- Yes
- No
If yes, please provide the following information:
Who is the third party/freight forwarder?
- Company
- Individual
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
5. Intended use of the item
Please describe the intended use of the item. Be specific.
6. Weapons applications
Will the export support the design, development, production, stockpiling or use of nuclear explosive devices, chemical or biological weapons, or missiles?
- Yes
- No
7. Restrictions on public release
Are there any restrictions on the public release of the exported item (e.g., publication restrictions or non-disclosure agreements)?
- Yes
- No
Signature
Date
MM slash DD slash YYYY
Print Name

Of export-controlled activities

1. Item to be exported

2. Recipient

3. Additional users/recipients

4. Third party (freight forwarder) used for export

5. Intended use of the item

6. Weapons applications

7. Restrictions on public release