Restricted Item Disclosure Form
Applicant Information
Full Name
Organization / Department
Email Address
Date of Submission
Item Details
Item Name
Description of Item
Quantity
Purpose of Use
Intended Location of Use
Duration of Use
Handling and Storage Arrangements
Declaration
I hereby declare that the above information is true and correct to the best of my knowledge and that I will comply with all applicable regulations governing restricted items.
Applicant Signature
Date