Department Export Compliance Questionnaire - Global Education ...
Department Export Compliance Questionnaire - Global Education ...
Department Export Compliance Questionnaire - Global Education ...
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I-‐129 <strong>Export</strong> <strong>Compliance</strong> <strong>Questionnaire</strong> (cont’d)<br />
Name of employee (beneficiary):_______________________________________________________ <br />
Last <br />
First <br />
Country of Citizenship___________________________ VCU Working title______________________<br />
Employing department (petitioner______________________________________________________<br />
Supervisor and/or Principal Investigator’s name______________________________________________ <br />
Phone _________________________________ E-‐mail _________________________________ <br />
Personnel Administrator ____________________________________________________________ <br />
Phone _________________________________ E-‐mail _________________________________<br />
The immediate supervisor and if applicable, the principal investigator must answer the following questions. <br />
Please answer to the best of your ability. If there is no answer, please write “n/a” on line: <br />
List the external sources of funding that will be used to support the employee's salary and, if applicable, his/her research. <br />
___________________________________________________________________________ <br />
If applicable, list VCU Grant or Proposal Number______________________________________________ <br />
If applicable, list VCU Grant or Proposal Title ________________________________________________ <br />
Characterize the Research to be Performed (Basic, Applied, Product Development, Testing, etc) and describe the specific <br />
purpose and technology area of research. <br />
___________________________________________________________________________<br />
___________________________________________________________________________ <br />
Will the employee be provided with any sponsor or 3 rd party proprietary or confidential information, materials, or software? <br />
If so, please provide the description. <br />
___________________________________________________________________________<br />
___________________________________________________________________________ <br />
Will the employee be provided with any government furnished equipment, information, or software? If so, please provide <br />
the description. <br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
Additional comments or questions? <br />
___________________________________________________________________________<br />
___________________________________________________________________________ <br />
I certify that I have answered these questions fully and to the best of my ability. <br />
Principal Investigator <br />
or Immediate Supervisor ____________________________________________________ Date_______________________ <br />
(printed name) <br />
(signature in blue ink) <br />
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