Form DHS-1640-0036 DHS Industry Outreach Information Form

NOTE: Please DO NOT supply any business proprietary information. Answer all questions as thoroughly as possible, as this
information is used to help determine the suitability of your company’s capabilities to the current and future needs of S&T.
CONTACT INFORMATION:
1. Business Name:
2. Business Street Address:

City

State

Company Headquarters

Sub-Division

Zip Code

3. Business Contact Information:
General Phone Number:

General Email Address:

4. Company Website:
5. How did you hear about S&T?

6. Company Classification (check all categories that apply):
Large Business
8(a) Certified
Other than Small Business:

Small Business (SB)
Service Disabled Veteran-Owned SB

NAICS Code:

HUB Zone
Veteran-Owned

Woman-Owned Business
Woman-Owned SB

DUNS Number:

7. Is your product on a Government-wide Acquisition Contract or any federal Indefinite Delivery Indefinite Quantity Contract?
8. Is your company currently doing business with DHS?

Yes

Yes

No

No

If yes, please provide name of DHS agency/person:
9. Have you met with a S&T program office representative within the last twelve months?

Yes

No

If yes, please provide names:
10. Describe your past experiences working with DHS/DHS S&T (Vendor, Supplier, Performer, Grantee, etc.):

*See the Product Realization Guide for additional TRL and MRL information:
http://www.dhs.gov/xlibrary/assets/st_product_realization_chart_version_1-4.pdf

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NOTE: Please DO NOT supply any business proprietary information. Answer all questions as thoroughly as possible, as this
information is used to help determine the suitability of your company’s capabilities to the current and future needs of S&T.
TECHNICAL CAPABILITIES: If you have an existing capability/technology, please provide a brief description of your capability/technology. This includes
the current stage of the technology, its Technology Readiness Level (TRL), and its current Manufacturing Readiness Level (MRL).
Technical Capability (please select type from the list):

Advanced Manufacturing/Automation

Technology or Service 1:
Description:

Current TRL*:

Current MRL*:

S&T office to which your product applies:
Why your product is unique and valuable to DHS:

Technical Capability (please select type from the list):

Advanced Manufacturing/Automation

Technology or Service 2:
Description:

Current TRL*:

Current MRL*:

S&T office to which your product applies:
Why your product is unique and valuable to DHS:

Submit Form

Click “Submit” or send this form directly to: SandT.Innovation@hq.dhs.gov

*See the Product Realization Guide for additional TRL and MRL information:
http://www.dhs.gov/xlibrary/assets/st_product_realization_chart_version_1-4.pdf

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