\documentclass[]{report}   % list options between brackets
\usepackage{graphicx}              % list packages between braces

% type user-defined commands here

\begin{document}

\title{JPL EXPORT ADMINISTRATION \\ DOCUMENT REVIEW RECORD}   % type title between braces
\author{Tom Scavo}         % type author(s) between braces
\date{October 27, 1995}    % type date between braces
%\maketitle


\begin{center}
\begin{tabular}{ |c|c| }
\hline
JPL EXPORT ADMINISTRATION \\
\textit{ DOCUMENT REVIEW RECORD} \\
\hline
\end{tabular}
\end{center}

\hfill Log \#: \underline{\input{LogNumber}}

\vspace{1cm}
\noindent (Note: This form and process do not replace the procedures described in JPL Policy relating to review and approval of proposals and contractual 
documents. This process is intended to document the review and coordination of requests to ascertain the export control ramifications relating to specific 
documents. Export Administration signature does not convey authority to export or release the "Exporter of Record" from any export laws or regulations.)\\

\noindent \textbf{Program:} \underline{ISSM: Ice Sheet System Model} \\ \\
\noindent \textbf{Person Requesting or Initiating Export}: \underline{Dr. Eric Larour}\\ \\
\noindent \textbf{Date Received}: \underline{\input{Date}}\\ \\
\noindent \textbf{Document Title/Description}: ISSM changes from revision \input{r1} to revision \input{r2} \\ \\
\noindent \textbf{Release to:} \underline{http://issm.ess.uci.edu/svn/issm/issm/trunk on ISSM svn repository}\\ \\
\noindent \textbf{JPL Intranet:} \underline{murdo.jpl.nasa.gov/proj/ice/larour/issm-uci/trunk-jpl}\\ \\

\noindent \textbf{Disposition: 6 } 
Does not contain export-controlled information. May be released/disclosed as requested subject to 
Company guidelines on protection of proprietary information (if applicable). \\

\noindent \textbf{Comments:}  see table of changes below. \\ \\
\noindent \textbf{Reviewed by ISSM Export Transfer Liaison:} Dr. Eric Larour \hfill \textbf{Date:} \input{Date} \\ 
\includegraphics[scale=1]{signature}

\noindent JPL Export Administration Form TBS – June 29, 2011

\begin{center}
\line(1,0){250}
\end{center}

\noindent \textbf{Disposition:} \\
1:	  Public Domain Information (Ref ITAR Section 120.11) \\
2:	  Qualifies for ITAR Exemption				 \\
3:	  Covered by Department of State License/Agreement Number					  \\
4:	  Covered by Department of Commerce validated license or exception				 \\
5:	  New License Required \\
6:	  Does not contain export-controlled information.  May be released/disclosed as requested subject
   to Company guidelines on protection of proprietary information (if applicable). \\
7:	 Other (specify)   
\begin{center}
\line(1,0){250}
\end{center}


\input{log}

\end{document}
