TIME PERIODS:

TERM: ____/____/____ THROUGH ____/____/____
OPTION(s) TO EXTEND : YES____ NO_____ HOW MANY_____ HOW LONG_____
REVOCATION PERIOD OF 120 DAYS OR LESS IS ACCEPTABLE TO:

DEPARTMENT: THE DEPARTMENT/ENTITY REQUESTING THE PREPARATION AND EXECUTION OF THE LICENSE AGREEMENT.

LICENSE INITIATOR: THE PERSON IN THE DEPARTMENT WHO IS KNOWLEDGEABLE OF ALL THE DETAILS CONCERNING AND OBJECTIVES OF THE PROPOSED LICENSE ACTIVITY.

PHONE NUMBER/EXTENSION: TELEPHONE NUMBER AT WHICH THE LICENSE INITIATOR MAY BE REACHED.

FAX NUMBER: FAX NUMBER AT WHICH THE LICENSE INITIATOR MAY BE REACHED.

MAIL CODE: MAIL CODE AT WHICH THE LICENSE INITIATOR MAY BE REACHED.

E-MAIL ADDRESS: E-MAIL ADDRESS AT WHICH THE LICENSE INITIATOR MAY BE REACHED.

INDEX #: INDEX NUMBER IN WHICH1) THE REAL ESTATE DEVELOPMENT DEPARTMENT MAY USE FOR PURPOSES OF REIMBURSEMENT FOR EXCESSIVE COPYING OR REQUIRED MAILING/OVERNIGHT MAIL EXPENSES AND/OR 2) FD&C OR EH&S MAY USE FOR PURPOSES OF INSPECTION/REVIEW RECHARGES.

EXTERNAL ENTITY: LEGAL NAME IN WHICH THE EXTERNAL ENTITY WILL ENTER THE LICENSE AGREEMENT. IF THE EXTERNAL ENTITY OPERATES ITS BUSINESS UNDER ANOTHER NAME, I.E., “DBA” (DOING BUSINESS AS), PLEASE NOTE IT.

TYPE OF BUSINESS ENTITY: THE SPECIFIC TYPE OF BUSINESS THE EXTERNAL ENTITY OPERATES UNDER, I.E., SOLE PROPRIETORSHIP, PARTNERSHIP (GENERAL, LIMITED, ETC.), LIMITED LIABILITY COMPANY, CORPORATION (FOR PROFIT, NOT FOR PROFIT, ETC.).

PHYSICAL ADDRESS: THE EXTERNAL ENTITY’S PHYSICAL ADDRESS OF BUSINESS. (STREET, CITY, STATE, ZIP CODE)

MAILING ADDRESS: THE EXTERNAL ENTITY’S MAILING ADDRESS THAT CAN BE USED FOR OFFICIAL NOTIFICATION. THIS ADDRESS MAY BE THE SAME AS THE PHYSICAL ADDRESS.

CONTACT NAME: THE CONTACT PERSON FOR THE EXTERNAL ENTITY.

POSITION/TITLE: THE POSITION/TITLE OF THE CONTACT PERSON AT THE EXTERNAL ENTITY.

ADDRESS: THE MAILING ADDRESS OF THE CONTACT PERSON AT THE EXTERNAL ENTITY.

PHONE NUMBER/EXTENSION: PHONE NUMBER FOR CONTACT PERSON AT THE EXTERNAL ENTITY.

FAX NUMBER: FAX NUMBER FOR CONTACT PERSON AT THE EXTERNAL ENTITY.

UC PROPERTY DESCRIPTION: PLEASE REFER TO EXHIBIT IV.E.-1 FOR THE NAME OF THE UC PROPERTY TO BE LICENSED TO THE EXTERNAL ENTITY AND DESIGNATE THE APPROXIMATE SQUARE FOOTAGE AND THE AREA OF THE PROPERTY TO BE USED.

TYPE OF LICENSE AGREEMENT:

EVENT PARKING
TELECOMMUNICATIONS
ATM SERVICES
CONSTRUCTION STAGING
RESEARCH RELATED
GLIDER ACTIVITIES
OTHER (SPECIFY)

PURPOSE OF PROPOSED LICENSE AGREEMENT: WHY IS THE LICENSE REQUIRED.

RELATIONSHIP BETWEEN MASTER AGREEMENT/GRANT AND PROPOSED LICENSE AGREEMENT: PLEASE CONFIRM WHETHER A MASTER AGREEMENT OR GRANT EXISTS, A GENERAL DESCRIPTION OF SUCH AGREEMENT OR GRANT, AND ANY DETAILS THAT MAY AFFECT THE PROPOSED LICENSED AGREEMENT.

TIME PERIODS:

TERM: START AND END DATES OF THE LICENSE AGREEMENT.

OPTION(S) TO EXTEND: IS IT AGREEABLE TO PROVIDE THE EXTERNAL ENTITY WITH THE OPPORTUNITY(IES) TO EXTEND THE LICENSE AGREEMENT, AT ITS SOLE ELECTION, BEYOND THE TERM REFERENCED IN #19? IF YES, PLEASE PROVIDE HOW MANY OPTIONS AND THEIR RESPECTIVE DURATION, E.G., ONE FIVE-YEAR PERIOD, TWO SIX-MONTH PERIODS, ETC.

REVOCATION PERIOD: THE CANCELLATION OF THE LICENSE AGREEMENT BY A PARTY BY MEANS OF NOTIFYING THE OTHER PARTY IN WRITING; MAY BE UNILATERAL OR BILATERAL DEPENDING UPON THE WRITTEN PROVISION.

HOURS OF OPERATION/USE: SPECIFY THE HOURS THE LICENSED ACTIVITY IS TO TAKE PLACE ON A DAILY BASIS.

DAYS OF OPERATION/USE: SPECIFY WHAT DAYS OF THE WEEK THE EXTERNAL ENTITY WILL USE THE LICENSED PROPERTY.

CONSIDERATION/REMUNERATION:

USER FEE: THE FEE CHARGED TO THE EXTERNAL ENTITY BY THE UNIVERSITY FOR USE OF THE LICENSED PROPERTY.

CONSIDERATION OTHER THAN USER FEE: MONEY, SERVICES, REAL OR PERSONAL PROPERTY, ETC., PAID TO THE UNIVERSITY IN EXCHANGE FOR USE OF THE LICENSED PROPERTY.

CHARGEABLE UNIVERSITY SERVICES - SERVICES PROVIDED AND CHARGED BY A UCSD/UCSDMC DEPARTMENT/ENTITY, E.G., PPS, EH&S, HOUSING/DINING, TO THE EXTERNAL ENTITY.

INSURANCE/INDEMNIFICATION:

A COPY OF THE UNIVERSITY’S STANDARD INSURANCE AND INDEMNIFICATION LANGUAGE, FOR PURPOSES OF PROVIDING A COPY TO THE EXTERNAL ENTITY FOR ITS REVIEW, CAN BE OBTAINED THROUGH RED UPON REQUEST. ANY REVISION REQUESTS OR SUBSTITUTION MUST BE REVIEWED AND APPROVED BY UCSD’S RISK MANAGEMENT.

GOVERNING AUTHORITIES:

NAME OF GOVERNING AUTHORITY: NAME OF GOVERNMENT AGENCY REQUIRING REVIEW/APPROVAL.

DESCRIBE REQUIREMENT IN DETAIL: PROVIDE WHAT PAPERWORK OR PROCEDURE IS REQUIRED BY THE GOVERNING AUTHORITY TO OBTAIN ITS REVIEW/APPROVAL.

NAME OF CONTACT: NAME OF CONTACT AT GOVERNING AUTHORITY

POSITION/TITLE OF CONTACT: POSITION/TITLE OF CONTACT AT GOVERNING AUTHORITY

ADDRESS: ADDRESS OF CONTACT AT GOVERNING AUTHORITY

PHONE: PHONE NUMBER OF CONTACT AT GOVERNING AUTHORITY

FAX: FAX NUMBER OF CONTACT AT GOVERNING AUTHORITY

NOTICE SECTION:

NAME: NAME OF PERSON AT EXTERNAL ENTITY TO RECEIVE OFFICIAL NOTICES

TITLE: TITLE OF PERSON AT EXTERNAL ENTITY TO RECEIVE OFFICIAL NOTICES

STREET: STREET ADDRESS OF PERSON AT EXTERNAL ENTITY TO RECEIVE OFFICIAL NOTICES

CITY/ST/ZIP: CITY/STATE/ZIP CODE ADDRESS OF PERSON AT EXTERNAL ENTITY TO RECEIVE OFFICIAL NOTICES

DESCRIPTIONS:

DESCRIPTION OF OPERATION/PROCEDURE OF ACTIVITY: DESCRIBE HOW ACTIVITY IS TO OPERATE OR PROCEED AT THE LICENSED PROPERTY.

DESCRIPTION OF HOW LICENSE PROPERTY WILL BE ACCESSED: HOW WILL THE EXTERNAL ENTITY OR ITS INVITED GUESTS ACCESS THE PROPERTY FOR PURPOSES OF USING IT? IS THERE A SPECIAL ROUTE WILL SIGNAGE BE REQUIRED? WILL THE UCSD POLICE DEPARTMENT NEED TO BE ADVISED? WILL PARKING NEED TO BE ADVISED?

UNIVERSITY’S OBLIGATIONS/DUTIES: BRIEFLY LIST ALL FUNCTIONS/PROVISIONS THE UNIVERSITY IS EXPECTED TO PERFORM/PROVIDE AS AGREED UPON BETWEEN THE PARTIES.

EXTERNAL ENTITY’S OBLIGATIONS/DUTIES: BRIEFLY LIST ALL FUNCTIONS/PROVISIONS THE EXTERNAL ENTITY IS EXPECTED TO PERFORM/PROVIDE AS AGREED UPON BETWEEN THE PARTIES.

8/12/97