Form NTIS FM101 NTIS FM101 NTIS Limited Access Death Master File Accredited Conform

U.S. Department of Commerce
National Technical Information Service

Limited Access Death Master File
Accredited Conformity Assessment Body
Application Form for Firewalled Status
This form is required ONLY for an Accredited Conformity Assessment Body (ACAB) owned,
managed, or controlled by the Person or Certified Person, as defined in 15 CFR 1110.2, that it is
assessing for access to the Limited Access Death Master File (LADMF).
1. The undersigned hereby represents and warrants that he or she is authorized to make this certification on
behalf of, and to bind, the ACAB applying for firewalled status pursuant to 15 CFR 1110. 502.
2. The undersigned certifies that the ACAB is “owned, managed or controlled,” as that term is defined in 15
CFR 1110.501, by the following Person or Certified Person:
Enter Legal Name of Person or Certified Person:

3. The undersigned further certifies that assessment or audit by the ACAB would provide equal or greater
assurance that the Person or Certified Person has information security systems, facilities, and procedures
in place to protect the security of the LADMF than would the Person’s or Certified Person’s use of an
independent third party conformity assessment body as required by 15 CFR 1110.502(b)(1).
4. In making the certification in paragraph 3., the undersigned states that the ACAB makes this assurance
based upon the following facts:
Explain the basis for assurances:

5. The undersigned further certifies that the ACAB has established procedures to ensure that, as required by
15 CFR 1110.502(b)(2):
(i) Its attestations and audits are protected from undue influence by the Person or Certified Person
that is the subject of attestation or audit by the organization, or by any other interested party;
(ii) NTIS will be notified promptly of any attempt by the Person or Certified Person that is the
subject of attestation or audit by the organization, or by any other interested party, to hide or
exert undue influence over an attestation or audit; and
(iii) Allegations of undue influence may be reported confidentially to NTIS.
6. In making the certification in paragraph 5., the undersigned states that the ACAB makes these
representations based upon the following facts:
Explain the procedures:

LADMF Application Form for Firewalled Status

NTIS FM101
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7. The undersigned agrees that the ACAB will cooperate in response to any request from NTIS to verify the
accuracy, veracity and/or completeness of the information received in connection with this application
for firewalled status.
8. The undersigned hereby declares that all certifications and statements made herein are true to the best of
his or her knowledge and belief, and further that these certifications and statements were made with the
knowledge that willful false statements and the like so made are punishable by fine or imprisonment of
not more than five (5) years, or both, under 18 U.S.C. Section 1001.
Signature: ______________________________________________________________
Name: ___________________________________________________________________________
Corporate Name: __________________________________________________________________
Address: _________________________________________________________________________
_________________________________________________________________________________
Phone Number: ____________________________________________________________________
Email: ___________________________________________________________________________
_________________________________________________________________________________
Date: ____________________________________________________________________________
Fax to 703-605-6900
National Technical Information Service
U.S. Department of Commerce
5301 Shawnee Rd.
Alexandria, VA 22312
This collection of information contains Paperwork Reduction Act (PRA) requirements approved by the Office of
Management and Budget (OMB). Notwithstanding any other provisions of the law, no person is required to
respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information
subject to the requirements of the PRA unless that collection of information displays a currently valid OMB
control number. Public reporting burden for this collection is estimated to be 1 hour per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and
completing and reviewing the collection of information.
Send comments regarding this burden estimate or any aspect of this collection of information, including
suggestions for reducing this burden, to the National Technical Information Service, Attn: John Hounsell,
National Technical Information Service, 5301 Shawnee Rd, Alexandria, VA 22313; jhounsell@ntis.gov, (703-6056184).
OMB Control #0692-XXX
Expiration date: XX/XX/XXXX
NTIS FM101

LADMF Application Form for Firewalled Status

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