Attestation Form Template - Research Compliance & Integrity (Rci)
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1EXPORT CONTROL: ATTESTATION FORM
This form should be completed by the principal investigator who will be supervising the visa beneficiary (i.e. the nonimmigrant
researcher on whose behalf the University is filing the I-129 petition), or the individual who is otherwise knowledgeable about the
beneficiary’s intended work.
Beneficiary’s Family Name:
Beneficiary’s First Name:
Beneficiary’s Citizenship(s):
Department Sponsoring Beneficiary:
PI or Supervisor (Name, Title, Phone #, Email):
If there are any questions regarding the statements below, please contact the Research Compliance and Integrity office at
(530) 754-7754.
Principal Investigator or Supervisor - Attestation
For the purpose of filing the I-129 petition, I attest to the following statements:
☐ True
The research agreement (e.g., grant or contract) WAS reviewed and executed/signed by the Office of Research or UC
Davis Health System Sponsored Programs and/or Contracts unit(s).
☐ False The research agreement (e.g., grant or contract) WAS NOT reviewed, NOR executed/signed by the Office of Research or
UC Davis Health System Sponsored Programs and/or Contracts unit(s).
☐ True
The research project on which the beneficiary will be working DOES NOT involve access to:
Technical Information that has been stamped “Export Controlled”
rd
Sponsor or 3
Party Proprietary Information
Confidential Information
Confidential Materials
Confidential Software and Equipment
☐ False The research project on which the beneficiary will be working DOES involve access to the above items.
The beneficiary WILL NOT work on military or space applications or “dual-use” technologies that have potential
☐ True
applications to military/proliferation purposes in additional to the usual commercial uses. For example: Newly developed
night vision technology or GPS technology used to observe nocturnal animals may have a "dual use" even though it's
primary purpose is not obviously military in nature but has the potential for military use.
☐ False The beneficiary MAY work on military or space applications or “dual-use” technologies that have potential applications to
military/proliferation purposes in additional to the usual commercial uses.
I hereby attest that I have used all reasonable diligence in preparing this Export Control- Attestation Form and, to the best
of my knowledge; it is true, complete and accurate.
Please note: this form must have an original signature.
_________________________________________________
________________________
Signature, Principal Investigator/ Supervisor
Date
If all answers above are answered, please include this form with the H-1B or O-1 packet request that will be submitted to
Services for International Students and Scholars (SISS) for the above-referenced beneficiary. If you have been unable to
Export Control – Supplement to I-129 Attestation
attest to the above statements, please complete and submit an
Form.
Research Compliance & Integrity (RCI) / Services for International Students and Scholars (SISS) – 09/2011
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