Safe Harbor Self-Certification Form

Certify with Safe Harbor!

OMB clearance number 0625-0239
Expires: 06/30/07

View Our Privacy Statement

CERTIFYING AN ORGANIZATION'S ADHERENCE TO THE SAFE HARBOR
To expedite the certification process, prepare the required information before completing this form. (See
Information Required for Certification) Please note that it is necessary to complete all fields except
those with asterisk(*).
If you have any difficulty completing this form or have any other questions concerning the Safe Harbor
self-certification process, please contact Damon C. Greer at the International Trade Administration,
Department of Commerce, damon.greer@mail.doc.gov, or 202-482-5023.
Public reporting for this collection is estimated to range from 20-40 minutes per response, including the time for
reviewing instructions, and completing and reviewing the collection of information. All responses to this
collection of information are voluntary, and will be provided confidentially to the extent allowed under the
Freedom of Information Act. Notwithstanding any other provisions of law, no person is required to respond to
nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB
Control Number. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Reports Clearance Officer, International Trade
Administration, Department of Commerce, Room 4001, 14th and Constitution Avenue, N.W., Washington, D.C.
20230.

ORGANIZATION INFORMATION
Organization Name:
Address:
City:
State:

Select your State

Zip:
Phone:
*Fax:

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Website: (Optional) http://
ORGANIZATION CONTACT INFORMATION (FOR HANDLING OF COMPLAINTS, ACCESS
REQUESTS, AND ANY OTHER ISSUES ARISING UNDER THE SAFE HARBOR)
*Contact Office:
Contact Name: (Optional)
Contact Title: (Optional)
*Contact Phone:
*Contact Fax:
*Contact Email:
CORPORATE OFFICER WHO IS CERTIFYING THE ORGANIZATION'S ADHERENCE TO THE
SAFE HARBOR FRAMEWORK
*Corporate Officer
Name:
*Corporate Officer
Title:
*Corporate Officer
Phone:
*Corporate Officer Fax:
*Corporate Officer
Email:
DESCRIPTION OF THE ACTIVITIES OF THE ORGANIZATION WITH RESPECT TO
PERSONAL INFORMATION RECEIVED FROM THE EU

DESCRIPTION OF THE ORGANIZATION'S PRIVACY POLICY FOR PERSONAL
INFORMATION
*Please enter the effective date of your organization's privacy policy:

*Please provide the location of your organization's privacy policy:
http://

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Certify with Safe Harbor!

*Please indicate the appropriate statutory body that has jurisdiction to hear any claims against the
organization regarding possible unfair or deceptive practices and violations of laws or regulations
governing privacy: Select Statutory Body
List any privacy programs in which your organization is a member for safe harbor purposes:

(See FAQ 6)
*What is your organization's verification method (e.g., In-house, Third Party. See FAQ 7)

What independent recourse mechanism(s) is(are) available to investigate unresolved complaints (e.g.,
private sector developed dispute resolution mechanisms that incorporate the safe harbor framework or
EU data protection authorities.
(See FAQ 11)?

What personal data processed by your organization is covered by the safe harbor? (e.g., off-line, on-line,
manually processed data, human resources data)

Do you plan to cover human resources data?
Select Appropriate Response
If yes, you need to agree to cooperate and comply with the European Data Protection Authorities (See
FAQs 5 & 9). Do you agree to cooperate and comply with the European Data Protection Authorities?
Select Appropriate Response
Which EU/EEA Countries do you receive information from? (Select all that apply)
None
Cyprus
Finland
Hungary
Latvia
Malta
Portugal
Spain
Austria
Czech Republic
France
Iceland
Liechtenstein
Netherlands
Romania
Sweden
Belgium
Denmark
Germany
Ireland
Lithuania
Norway
Slovakia
United
Kingdom
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Certify with Safe Harbor!

Bulgaria

Estonia

Greece

Italy

Luxembourg

Poland

Slovenia

*Please select your appropriate Industry Sectors. (Select up to 4)
Select 1st Industry Sector
Select 2nd Industry Sector
Select 3rd Industry Sector
Select 3rd Industry Sector
*Please select the appropriate level of sales?: Enter Sales Amount
*How many employees does your organization have?: Enter Number of Employees
Please print out your completed form now to verify that the information provided is correct and to retain
a copy for your files.
If you are ready to submit the self certification for your organization simply click the SUBMIT button
below.
SUBMIT

Return to Welcome | Safe Harbor Overview | Safe Harbor Documents
Workbook | Safe Harbor List | Information Required for Certification

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