Form DHS Form 10003 DHS Form 10003 Notice of License

OMB Control No. 1640-0001
Expires: 03/31/2013

NOTICE OF LICENSE OF QUALIFIED ANTI-TERRORISM
TECHNOLOGY
Except as may be restricted by the terms and conditions of a particular Designation or
Certification, a SAFETY Act Designation or Certification may apply to any other person, firm,
or other entity to which the Seller licenses (exclusively or non-exclusively) the right to sell the
Technology, in the same manner and to the same extent that such Designation applies to the
original Seller. Sellers wishing to license the right to sell their Technology and its Designation or
Certification should submit a “Notice of License of Qualified Anti-Terrorism Technology”
within 30 days of the commencement of the license.

(Notice of License Form on following page)

Privacy Act Notice: DHS Authority to Collect This Information: 6 U.S.C. §§ 441–444 (the “SAFETY Act”) and 6 C.F.R. Part 25, 71 Fed. Reg.
33147, 33159. Principal Purposes: DHS collects telephone numbers, addresses, and licensing information for the purpose of contacting individuals
seeking liability protections on issues related to the SAFETY ACT application process and those wishing to license the right to sell their Technology
and its Designation or Certification. Routine Uses and Sharing: In general, DHS will not use this information for any purpose other than DHS
personnel contacting the individual. However, DHS may release this information of an individual on a case-by-case basis as described in the S&T
SAFETY Act System of Records Notice (SORN), which can be found at: www.dhs.gov/privacy. Disclosure: Submission of this information is
voluntary and an individual may opt not to provide the requested information or to provide only some of the information DHS requests. If an
individual chooses to opt not to provide some or all of the requested information, DHS may not be able to process the individual’s request.
PRA Burden Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this
information collection unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 16400001 and this form will expire on 03/31/2013. The estimated average time to complete this form is 50 hours per respondent. If you have any
comments regarding the burden estimate you can write to Department of Homeland Security, Science and Technology Directorate, Washington, DC
20528.
DHS Form 10003 (10/06)

NOTICE OF LICENSE OF QUALIFIED ANTI-TERRORISM
TECHNOLOGY
L1. Seller Name: _______________________________________________
L2. QATT information
L2.1. QATT Name: __________________________________________
L2.2. QATT Application ID Number: ____________________________
L3. Name of Licensee: __________________________________________
L3.1. Licensee Place of Incorporation: ____________________________
L4. Method of License (choose one):
Exclusive
Non-Exclusive
L5. Date of Commencement of License: ____/____/20___
L6. Term of License: ____________________________________________
L7. Provide a description of the license agreement including an affirmation that
SAFETY Act protections only attach to the Technology that is described in
Exhibit A of the licensor’s letter of Designation or Certification, as applicable.
Attach supporting information as necessary. Indicate that the transferee is
cognizant of the requirement to meet the transferor’s insurance requirements
and any other special conditions which might affect the deployment of the
licensed Technology.
L8. Provide information regarding the described licensing effect on the QATTs
safety or efficacy, or risk(s) associated with its deployment.
If POCs are provided as sources of information or testimonials, check below to
indicate that you have contacted them and that they are expecting to hear from
DHS related to your Technology. Also, indicate below what information we should
expect from each POC.

DHS Form 10003 (10/06)

The POCs are expecting contact from DHS. The information the POC can
provide or verify is:
____________________________________________________________
____________________________________________________________
____________________________________________________________

DECLARATION FOR WRITTEN SUBMISSIONS
I declare, to the best of my knowledge and belief, that the information provided in
response to the questions set forth in this Application for SAFETY Act liability protections
is true, factual, and correct, and that I am an authorized agent of the Applicant.
Prepared By: ________________________________

Title (if applicable): _______________

Signature: ______________________________________________ Date: ___/___/20__

The signature of the Preparer must be notarized below:
State of:

_______________

Subscribed and sworn before me this

Notary Public:

_____

day of

_____________________

___________________________________________________

My Commission Expires on:

DHS Form 10003 (10/06)

County of: __________________________

________________________________________

Instructions for Completing Notice of License Form:
Item L1. Seller Name
Enter the name of the current Seller of the QATT whose Designation you wish to
license.

Item L2. QATT Information
Item L2.1. QATT Name
Enter the name of the QATT as it appears in the Seller’s most recent correspondence
with the OSAI.
Item L2.2. QATT Application Identification Number
Enter the Application Identification Number of the original Designation for this
QATT.

Item L3. Name
Enter the registration name of the Licensee. This should be the company or business
unit name used by the Licensee to register as a Seller. The recipient of the license
must be registered with the OSAI before the notice of license can take place. See
Chapter 5 of this kit for detailed instructions on how to register. Registration with
the OSAI does not commit the registrant to any further actions.
Item L3.1. Place of Incorporation
Identify the place where the transferee is incorporated.

Item L4. Method of License
Check the box corresponding to the type of License you are performing. Check
“Exclusive license” if the current Seller retains rights in the QATT and will not be
transferring any of these same transferred rights to anyone other than the Licensee
named in this form. Check “Non-exclusive license” if the current Seller retains rights
and may transfer some or all of those rights to entities other than the Licensee named
in this form.

Item L5. Date of Commencement of License
Enter the date of the commencement of the license or the proposed date if that has
not yet occurred. Use month/date/year format.

Item L6. Term of License
Enter term of license.

DHS Form 10003 (10/06)

Item L7. Description of License Agreement
Summarize the nature and terms of the License agreement. Attach additional sheets
if necessary.

Item L8. Effect
Please describe the effect the licensing will have on the QATT’s safety or efficacy and
provide any available supporting information.
If POCs are provided as sources of information or testimonials, please indicate that
you have contacted them and that they are expecting to hear from DHS related to
your Technology. Also, indicate what information we should expect from each POC.

Declaration
An authorized agent of the Applicant must sign and date this form before submitting
it to OSAI. For electronic or Web submissions, follow the instructions provided at
safetyact.gov.

DHS Form 10003 (10/06)