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 UMass Dartmouth

International Pre-Travel Export Control and Risk Form

Once completed, this form must be attached to the related Pre-Travel Authorization Request in Concur

(You can save this form and resume later if needed by using the link located at the top or the bottom of the form)

(Use same name and spelling as the “Request Name” field in your Concur Travel Request)
Traveler

(Please use same name and spelling as that in your Concur Travel Request)

(University of Massachusetts email address only)

Enter an email address here if you would like to CC this form to someone else when it's completed
(University of Massachusetts email address only)



(If you are both an employee and a student, please check both applicable boxes)

(Lookup U.S. Embassy or consulate)



Insurance and Emergency Services

(Review UMass International Travel Insurance Brochure)

Please review the UMass Travel Accident and Sickness Insurance brochure using the link provided above prior to proceeding.


(Download UMass travel accident and sickness insurance Travel Card)

Using the link provided above, please download the UMass Travel Accident and Sickness Insurance Travel Card before proceeding.

Traveler Contact Information While Traveling



(Include country code + city code)




(e.g. email, WhatsApp, We Chat, Instagram, Facebook name, Twitter name, etc.)

Program/Host Information



Emergency Contact Information
In-Country/On-site Emergency Contact:
(This can be a member of a partner organization/s, a personal contact, or anyone who will be on-site with you and who can be contacted in the event of an on-site emergency)
(Provide contact information for your in-country partner, collaborator, host organization and/or placement agency.  Please list additional partners below if there are more than one contact.)


(Include country code + city code)

Personal Emergency Contact:




Primary Campus Contact: (Campus Contact should be someone who will be in the United States during your Travel)




(Please note: communication should include a minimum of a check-in when you arrive on-site, at least one check-in communication during the program, and preferably weekly check-ins.)
Export Control/IT Review (required)







Please obtain the appropriate approvals prior to submitting your Pre-Travel Authorization.


(You can save this form and resume later if needed by using the link located at the top or the bottom of the form)













** If you are traveling with a university device, you are required to contact CITS for approval or to obtain a loaner device from CITS prior to travel.**

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