Please fill out this form on-line. After filling out this form, click on the "Get Checklist" button below. The next thing you will see on your monitor is a document suitable for printing. Print the document, sign it, and fax to Christine Ramos at 505-665-3125. If you have questions, call Christine at 505-665-6846 or e-mail at ctramos@lanl.gov.

Name of Facility

Is the person/facility you are requesting export to involved in any of the following activities?

(1) Nuclear explosive activities.

Yes No	Research on or development, design, manufacture, construction, testing or maintenance of any nuclear explosive device or components or subsystems of such a device?
Yes No	Are you a U.S. person involved in support activities where you know that the items will be used in the design, development, production, or use of nuclear explosive devices?

(2) Unsafeguarded* nuclear activities.

Research on, or development, design, manufacture, construction, operation, or maintenance of:

Yes No	a nuclear reactor
Yes No	a critical facility
Yes No	a facility for the fabrication of nuclear fuel
Yes No	a facility for the conversion of nuclear material from one form to another
Yes No	a storage installation

*Unsafeguarded means that there is no obligation on the part of the country to accept International Atomic Energy Agency (IAEA) safeguards at the relevant facility or installation that contains any source or special fissionable material (regardless of whether or not it contains such material at the time of export) or where any such obligation is not met.

(3) Safeguarded and unsafeguarded nuclear activities.

Nuclear fuel cycle activities, including research on a development, design, manufacture, construction, operation or maintenance of any of the following facilities:

Yes No	Facilities for the chemical processing of irradiated special nuclear or source material
Yes No	Facilities for the production of heavy water
Yes No	Facilities for the separation of isotopes of source and special nuclear material
Yes No	Facilities for the fabrication of nuclear reactor fuel containing plutonium

Yes No	Will the item(s) requested for export be used in the design, development, production or use of missiles?
Yes No	Is your facility involved in any activities involving the development of missiles?
Yes No	Does your facility have any direct or indirect assistance in the design, fabrication, operation or maintenance of rocket systems (including ballistic missile systems, space launch vehicles and sounding rockets) or in unmanned air vehicles systems (including cruise missile systems, target drones, remotely piloted vehicles and reconnaissance drones)?

Yes No	Will the item(s) requested for export be used in the design, development, production, stockpiling, or use of chemical or biological weapons?
Yes No	Would you refuse Los Alamos National Laboratory personnel access to parts of the plant other than those involved in the contract?