Form 1103-0117 Doing Business with the FBI “Submit your Idea” Form

Doing Business with the FBI “Submit your Idea” Form

Privacy Statement

The FBI is authorized to collect the information on this form by one or more of the following provisions: Title 28, United States Code, Sections 533 and 534; Title 41, United States Code, Section 3306; and Federal Acquisition Regulation (FAR) Part 10. The information requested will assist the FBI in "conducting market research to arrive at the most suitable approach to acquiring, distributing, and supporting supplies and services." FAR Part 10. Your participation is voluntary. The information collected on this form is protected by the Privacy Act of 1974, as amended, Title 5, United States Code section 552a, and is maintained in the FBI’s Central Records System, DOJ/FBI-002, a description of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998) and which may be viewed at https://www.govinfo.gov/content/pkg/FR-1998-02-20/pdf/98-4206.pdf

Capability Area of Interest* Drop Down: (TBD)

Idea / Proposal Title* Fill In Box

Company* Fill In Box

Organization Type* Drop Down:

Large Business
Small Business
Academic Institution
Govt Agency
FFRDC
Sole Proprietor
General Public

US-based company: Y/N

Is the company owned in whole or in part by a federal employee? Y/N

If yes, was the invention created at work and/or with federal funding? Y/N

Primary POC* Fill in Box

Telephone Number* Fill in Box

Primary Email Address* Fill in Box

Federal Employee: Y/N

If yes, provide Agency: Fill in Box

Technology Readiness Level * Drop Down:

Tier I: Basic Principles Observed and Reported

Tier 2: Technology Concept and/or Application Formulated

Tier 3: Analytical and Experimental Critical Function and/or Characteristic Proof of Concept

Tier 4: Validation in Laboratory Environment

Tier 5: Validation in Relevant Environment

Tier 6: Model or Prototype in Relevant Environment

Tier 7: Prototype Demonstration in an Actual Environment

Tier 8: Actual System Completed and “Qualified” Through Test and Demonstration

Tier 9: Actual System Proven Through Successful Operation

Synopsis (no more than 250 Fill in Box

words) *

GOV Labs/Contracts* Fill in Box

Patent Status * Drop Down:

Patented

Patent Pending

No Patent

N/A

I have read and understand the FBI’s Information Privacy Policy. Radio Button (Yes)*

I have read the FBI submission guidance and certify that my attachment meets all requirements. Radio Button (Yes)*

I certify that the content in my submission was created by (1) me; (2) my organization; and/or (3) an individual or organization who gave me permission to submit their content. Radio Button (Yes)*

Attachment guidelines:

1. You must submit a PDF. Other formats will not be reviewed.

2. Your PDF must not include any hyperlinks. (You can include URLs in the text, but do not link them.)

3. The first page of your submission must include:

• Capability area of interest

• Organization or individual name

• Phone number and email

• Website address (if applicable)

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