Fillable Export Certification Request Form Foreign National Employee (H-1B, (Texas Tech University-Health Sciences Center)

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Export Certification Request Form Foreign National Employee (H-1B, (Texas Tech University-Health Sciences Center)

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The Export Certification Request Form Foreign National Employee (H-1B, (Texas Tech University-Health Sciences Center) form is 3 pages long and contains:

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Export Certification Request Form Foreign National
Employee (H-1B, H-1B1, Chile/Singapore, and 0-1A) Petitions
Instructions: This form is intended to provide the Export Control Officer (ECO) with information necessary
to start the export assessment process. It is anticipated that an export license will not be required in most
cases. Should additional information be needed to complete the assessment, the ECO will work directly
with the Sponsor/Supervisor listed below.
Section A: Employee Information
First Name:
Middle Name:
Last Name:
Country of Birth:
Reason for
Application:
Country of Citizenship/Residenc
y:
E-mail Address:
(Provide the TTUHSC e-mai
l address for a current employee; any e-mail address is acceptable if the
TTUHSC e-mail address has not been assigned.)
Current Physical Address:
Current Employee - extension or update
Section B: Position Description
Job Title (employee’s):
Sponsoring Department (Home Department):
Supervisor Name (This should be the PI for Research Scholars or Post-Doctoral
Fellows. For faculty or staff positions this should be the employee’s direct supervisor):
List the sources of funding that will be used to support the employee’s salary and, if
applicable, their research. (This should include the grant number assigned by
Sponsored programs):
Will the employee have access to technology (software, equipment or materials)
specifically designed or developed for military (e.g. night vision, GPS Y-code, shielding,
UAVs or targeting algorithms) or space (e.g. rockets, missiles, satellites, space
telescopes or probes) applications? (If yes, provide a list of the military or space
technology below):
Section C: Research Information
Is research is part of the employee's job description? (If yes, provide a brief description
of the research project or program in the space below. If a specific project or program
has not been determined, describe the areas of interest or inquiry that the employee is
expected to pursue while at TTUHSC):
Will the employee be involved in any research or other scholarly activity that is NOT
intended for public dissemination? (If yes, summarize the export controls, contract
terms, publication restrictions, citizenship restrictions, etc. that may be associated with
the project below.):
Section D: Certification
Name of Person Completing This Form:
Phone Number:
E-mail address:
Date:
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Export Certification Request Form Foreign National Employee (H-1B, (Texas Tech University-Health Sciences Center)

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Completed 28 August 2020

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