Foreign Travel Form

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Name(Required)

First Last

Title(Required)

Faculty

Staff

Student

Volunteer

T-Number(Required)

Department:(Required)

Phone(Required)

Email(Required)

Enter Email Confirm Email

Date of Departure(Required)

MM slash DD slash YYYY

Date of Return(Required)

MM slash DD slash YYYY

What is the purpose of your travel?(Required)

Conference or Meeting

Research Grant

Class Trip

Study Abroad

Other

Provide the full name of the conference or meeting, including sponsor and website.(Required)

Name

Sponsor(Required)

Sponsor

Website(Required)

Website

Provide the grant award number(Required)

Do you plan to travel to an embargoed destination (Cuba, Iran, North Korea, Sudan, or Syria)?(Required)

Note: In addition to embargoed countries, certain other countries, such as Belarus, Burma, Libya, Somalia, Venezuela, and Zimbabwe, have seen increased restrictions.

Yes

Please describe why you will be going to an embargoed destination.(Required)

To which country or countries are you traveling?(Required)

Click on the + symbol to the right of the entry field to create additional rows for each country.

From where will the funding for this trip come?(Required)

Will you receive compensation for your travel expenses or other compensation from a foreign sponsor or government?(Required)

Yes

From whom?(Required)

Name specific places or persons (e.g., companies, universities, or professors) you will visit while you are there? Please list at least one place. If you are studying abroad, name the institution.(Required)

Click on the + symbol to the right of the entry field to create additional rows for each place or person.

Will you be taking any information or technology that is either A) not available in the public domain or education areas, B) classified, or C) subject to export control regulations (including materials in print or electronic versions)?(Required)

Export controlled materials include technology, software, and information related to the design, production, testing, maintenance, operation, modification, or use of controlled items or items with military applications. It does NOT include basic marketing information on function or purpose: information regarding general scientific, mathematical, or engineering principles commonly taught in universities: or information that is generally accessible in the public domain.

Yes

Please list the export controlled materials.(Required)

Are you taking any biological or hazardous materials abroad (including controlled toxins, genetic elements, or controlled chemicals/chemical compounds)?(Required)

Yes

Will you be presenting information at a conference/meeting that is NOT available in the public domain or does NOT constitute fundamental research?(Required)

Yes

Please explain.(Required)

Will you be attending a "closed" conference or meeting?(Required)

Yes

What is the purpose of the "closed" conference/meeting? (Explain in detail)(Required)

Will you provide a service or financial assistance to a foreign entity while traveling?(Required)

Yes

Please explain.(Required)

Do you plan to take a laptop, smart phone, or other equipment, data, technology, or specialized software when traveling abroad? If yes, an export license or license exception may be required, depending on what you are taking and the country to which you are traveling.(Required)

Contact the Export Control Officer (ECO) if you have any questions.

Yes

Please list the applicable technology/data/software.(Required)

Will the above‐mentioned item(s) be used ONLY as a “tool of the trade” i.e. to conduct UA LITTLE ROCK business (e.g., present at a conference, conduct research project, teach, etc.)?(Required)

If you plan to take University equipment, please complete the TMP form. If not, please complete the BAG form.

Yes

Will the item(s) be returned to the U.S. within 12 months?(Required)

Yes

Please explain.(Required)

If a license or a license exception is required, will the item(s) be under your physical possession or maintained in a secure environment, such as a locked or guarded facility, while the property is abroad?(Required)

Yes

Please explain.(Required)

Have you removed any export‐controlled information from electronic storage media (laptops, memory sticks, smart phones, etc.)?(Required)

Yes

I don’t have any export-controlled information

Are you sharing UA LITTLE ROCK developed, non‐commercial encryption software in source code or object code?(Required)

If yes, an export license may be required. Contact the Export Control Officer (ECO).

Yes

Will you be in possession of or share items, documents, information, or data related to export-controlled research?(Required)

Yes

Do you have any reason to believe that the information or software to be shared will have a military use?(Required)

Yes

Certify(Required)

I hereby certify that I have read and understand the information provided regarding compliance with export laws and regulations. I understand that I could be personally liable if I unlawfully export or disclose export controlled information or technology to foreign nationals without prior approval. I have provided complete information in responding to the questions listed above.

Agree

Initials(Required)

Date(Required)

MM slash DD slash YYYY

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