Section: 440-4 Exhibit D
Effective: 4/1/98
Supersedes:
Issuing Office: Real Estate Development (RED)
- INITIATING DEPARTMENT: YES___ NO___
- EXTERNAL ENTITY: YES____NO____
HOURS OF OPERATION/USE:_________________________DAYS OF OPERATION/USE:____________________
CONSIDERATION/REMUNERATION:
USER FEE ________________
CONSIDERATION OTHER THAN USER FEE (EXPLAIN) ________________________________________________________
ANY CHARGABLE UNIVERSITY SERVICES TO BE USED BY EXTERNAL ENTITY? YES: ____________ NO ______________
- IF YES, PLEASE DESCRIBE: _______________________________________
INSURACNE/INDEMNIFICATION:
IS UNIVERSITY'S STANDARD INSURANCE/INDEMNIFICATION ACCEPTABLE TO EXTERNAL ENITITY?:
YES __________ NO__________
(IF NOT, PLEASE PROVIDE COPY OF REVISED OR REPLACEMENT LANGUAGE PROVIDED BY EXTERNAL ENTITY.)GOVERNING AUTHORITIES:
IF A GOVERNING AUTHORITY REVIEW, APPROVAL, PERMIT, ETC. IS REQUIRED, PLEASE PROVIDE THE FOLLOWING INFORMATION:
- NAME OF GOVERNING AUTHORITY: ____________________________________
DESCRIBE REQUIREMENT IN DETAIL: ___________________________________
___________________________________________________________________
NAME OF CONTACT: ___________________POSITION/TITLE: ________________
ADDRESS: ___________________________________________________________
PHONE( ) ___________________ FAX ( ) _________________________
NOTICE SECTION:
PERSON/TITLE AT EXTERNAL ENTITY TO RECEIVE OFFICIAL NOTICES AS REQUIRED IN AGREEMENT:
- NAME: _____________________________________________
TITLE: _____________________________________________
STREET: ___________________________________________
CITY/ST/ZIP: ________________________________________
DESCRIPTION OF OPERATION/PROCEDURE OF ACTIVITY: (PLEASE REFER TO DIRECTIONS FOR ASSISTANCE)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________UNIVERSITY'S OBLIGATIONS/DUTIES: (PLEASE REFER TO DIRECTIONS FOR ASSISTANCE)
1. _________________________________________________________________________
2. _________________________________________________________________________
3. _________________________________________________________________________
4. _________________________________________________________________________
EXTERNAL ENTITY'S OBLIGATIONS/DUTIES: (PLEASE REFER TO DIRECTIONS FOR ASSISTANCE)
1. _________________________________________________________________________
2. _________________________________________________________________________
3. _________________________________________________________________________
4. _________________________________________________________________________
5. _________________________________________________________________________
- EXTERNAL ENTITY: YES____NO____
-
TELECOMMUNICATIONS
RESEARCH RELATED
OTHER (SPECIFY)
THE REGENTS AS A LICENSEE |
INITIATING PARTY INFORMATION |
DEPARTMENT: ____________________________________ LICENSE INITIATOR: ____________________________ PHONE NUMBER/EXTENSION: ________ FAX NUMBER: ________ MAIL CODE: ________ E-MAIL: ADDRESS: ________ INDEX # ______ (ANY MAILING OR FD&C/EH&S INSPECTIONS MAY BE CHARGED TO THIS INDEX NUMBER.) |
EXTERNAL ENTITY (LEGAL NAME):_________________________________________________________________ TYPE OF BUSINESS ENTITY (REFER TO DIRECTIONS):_________________________________________________ PHYSICAL ADDRESS: ____________________________________________________________________________ MAILING ADDRESS: _____________________________________________________________________________ CONTACT NAME: _____________________________POSITION TITLE: ___________________________________ ADDRESS: _____________________________________________________________________________________ PHONE NUMBER/EXTENTION: _____________________________FAX NUMBER: ____________________________ |
DETAILED INFORMATION |
|
TIME PERIODS: TERM: ____/____/____ THROUGH ____/____/____ |
THE REGENTS AS A LICENSOR |
|
NOTE: IF A LICENSE AGREEMENT HAS ALREADY BEEN PREPARED BY THE EXTERNAL ENTITY (LICENSOR), IT IS ONLY NECESSARY TO PROVIDE THE REQUESTED INFORMATION BELOW IF IT IS RELEVANT AND NOT ADDRESSED IN THE LICENSE AGREEMENT. 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. 8/12/97 ADDRESS OF LICENSED PROPERTY: PROVIDE THE ADDRESS OR DESCRIPTION OF PROPERTY TO BE LICENSED TO THE UNIVERSITY. ALSO DESIGNATE THE APPROXIMATE SQUARE FOOTAGE AND THE AREA OF THE PROPERTY TO BE USED. A MAP DEPICTING THE PROPERTY MAY BE REQUIRED. TYPE OF LICENSE AGREEMENT: PURPOSE OF PROPOSED LICENSE AGREEMENT: WHY IS THE LICENSE REQUIRED. DETAILED INFORMATION TIME PERIODS: TERM: START AND END DATES OF THE LICENSE AGREEMENT. OPTION(S) TO EXTEND: DOES THE DEPARTMENT WANT THE OPPORTUNITY(IES) TO EXTEND THE LICENSE AGREEMENT, AT THE UNIVERSITY’S 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. FINANCIAL INFORMATION: USER FEE: THE FEE TO BE PAID BY DEPARTMENTAL FUNDS FOR USE OF THE LICENSED PROPERTY. CONSIDERATION OTHER THAN USER FEE: MONEY, SERVICES, REAL OR PERSONAL PROPERTY, EXCHANGE OF RESEARCH DATA, ETC., PAID TO THE EXTERNAL ENTITY IN EXCHANGE FOR USE OF THE LICENSED PROPERTY. OTHER CHARGES THE DEPARTMENT OR THE UNIVERSITY IS LIABLE FOR: ANY OTHER EXPENSES TO BE INCURRED BY THE DEPARTMENT OTHER THAN THOSE ABOVE. INSURANCE/INDEMNIFICATION: IN MOST CASES, THE EXTERNAL ENTITY’S PREFERRED INSURANCE AND/OR INDEMNIFICATION LANGUAGE WILL ALREADY BE INCLUDED IN ITS LICENSE AGREEMENT FORM. IF IT IS NOT, A COPY OF THE UNIVERSITY’S STANDARD INSURANCE AND INDEMNIFICATION LANGUAGE MAY BE SUBMITTED TO THE EXTERNAL ENTITY FOR REVIEW/APROVAL. A COPY OF THE STANDARD LANGUAGE CAN BE OBTAINED THROUGH RED UPON REQUEST. IN EITHER CASE, 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 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. A SCOPE OF WORK OR PROTOCOL IS QUITE USEFUL WHEN THE LICENSE AGREEMENT IS RESEARCH RELATED. DESCRIPTION OF HOW LICENSE PROPERTY WILL BE ACCESSED: HOW WILL THE DEPARTMENT ACCESS THE PROPERTY FOR PURPOSES OF USING IT? IS THERE A SPECIAL ROUTE? WILL SIGNAGE BE REQUIRED? 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. |
Exhibit C.pdf | Exhibit D.pdf | Exhibit E.pdf | Exhibit F.pdf |
