University of California, Riverside

International Students and Scholars Office



Export Control Form


All of these fields are required. Please fill this form out completely.
Visa Beneficiary's Name: Last Name, First Name
Email:
Phone Number: (XXX)XXX-XXXX
Department:
Visa Beneficiary's Citizenship(s):
Name of Department Sponsoring Beneficiary:
Name of Supervising Principal Investigator (PI) or Supervisor:
Will the visa benficiary be working in one of the following areas: Biomedical Sciences, Computer Sciences, Space Sciences, Engineering, Physics, Chemistry, or other scientific discipline? Select one: Yes
No
Does the research agreement (e.g. grant or contract) on which the beneficiary will be working restrict or prohibit the participation of foreign persons in the project or the research team's right to publish any of the results? Yes
No
What is the Pamis Award Number or Fund Number for this research agreement (e.g. grant or contract)?:
Is there any non-standard language in the research agreement on which the beneficiary will be working regarding export control regulations? Yes
No
Does the research project on which the beneficiary will be working involve access to technical information that has been stamped "export controlled;" or will the beneficiary be provided with any sponsor or 3rd party proprietary or confidential information, materials, or software? Yes
No
Will the beneficiary work on military or space applications, or "dual-use" technologies that have potential applications to military/proliferation purposes in addition to the usual commercial uses? Yes
No

This certification questionnaire will be referred to the Office of Research for a further review of your case. You may also contact the Assistant Vice Chancellor for Research (AVCR) directly for questions and assistance at 951-827-3093 or (Charles.greer@ucr.edu). If you are unable to reach the AVCR, you can contact Cynthia Wells, Director of Sponsored Programs Administration, (951) 827-4918 or (Cynthia.wells@ucr.edu) for assistance.

Review your signature

By signing your signature, you hereby certify that you are familiar with the job duties and other particulars of employment of the visa beneficiary listed above, and hereby affirm that the contents of the foregoing certification questionnaire are true to the best of your knowledge, information and belief. You further understand that failure to accurately complete this questionnaire can result in U.S. Government export control violations for which civil and criminal penalties can be assessed against any individual (including a PI) found to have caused or facilitated a violation, and/or against the University of California.

More Information 

General Campus Information

University of California, Riverside
900 University Ave.
Riverside, CA 92521
Tel: (951) 827-1012

Department Information

International Students and Scholars Office
0321 Surge Building

Tel: (951) 827-4113
Fax: (951) 827-3248
E-mail: internationalscholars@ucr.edu

Footer