DHS Form 10010 REGISTRATION AS A SELLER OF ANTI-TERRORISM TECHNOLOGY

OMB Control No. 1640-0001 Expires: 03/31/2016

Department of Homeland Security

Science and Technology Directorate

REGISTRATION AS A SELLER OF ANTI-TERRORISM TECHNOLOGY

The initial step in applying for the liability protections available under the SAFETY Act or for requesting a Pre-Application Consultation is to register with OSAI. Registration can be done electronically at the SAFETY Act Web site (http://www.safetyact.gov). You can also register by mail, using the forms included in this kit, or you can download an electronic copy of the form, complete it, and mail in the electronic document on a compact disc. Mailed registrations (hard copy or CD) should be sent to:

U.S. Department of Homeland Security

ATTN: Office of SAFETY Act Implementation 245 Murray Lane, Building 410

Washington, D.C. 20528

Remember that physical mail sent to DHS is screened and processed, which may delay the Department’s response to your submission.

Registering with OSAI does not commit you to any further actions. The purpose of Registration is to establish an official point of contact for the Department to use in its interactions with you concerning your Technology and to create a unique identification number for you as a potential Seller. This identifier will help the Department track and maintain your application. The SAFETY Act application process is designed to be flexible and to involve ongoing dialogue with the Applicant. Appropriate “points of contact” will facilitate this dialogue. The Applicant’s point of contact may be any person you desire to coordinate your application and may include counsel, a representative of management, a technical expert or any other person you consider appropriate for this purpose.

(Registration 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 other identifying information for the purpose of contacting individuals seeking liability protections on issues related to the SAFETY ACT application process. 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 1640- 0001 and this form will expire on 03/31/2013. The estimated average time to complete this form is 30 minutes 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.

REGISTRATION AS A SELLER OF ANTI-TERRORISM TECHNOLOGY

ACTION

R1. Purpose of Registration (choose one): Initial Registration

Updated or Corrected Registration Information

REGISTRATION DATA

R2. Seller Name: R3. Data Universal Numbering System (DUNS) Number (if available): R4. North American Industry Classification System (NAICS) Code (if available):

POINT-OF-CONTACT INFORMATION

R5. Primary Point of Contact:

Name: Address: State/Province: Country: ZIP/Mail Code: Telephone No.: Fax No.: E-mail: E-mail Communication Authorized? Yes No

R6. Secondary Point of Contact (optional):

Name: Address: State/Province: Country: ZIP/Mail Code: Telephone No.: Fax No.: E-mail: E-mail Communication Authorized? Yes No

Instructions for Completing Registration Form:

Item R1. Purpose of Registration

If your company or business unit has not previously registered with OSAI, check “Initial registration.” A company may file more than one registration; certain companies may wish to file multiple registrations if it has multiple business units selling dissimilar types of Technologies. As a rule, the entity that sells the Technology is the entity that should register.

If you are updating or correcting previous registration information, check “Updated or Corrected Registration Information.” OSAI strongly encourages you to keep your registration information up to date. In particular, be sure to notify OSAI of any changes in contact information.

Registration Data Item R2. Seller Name

Enter the legal name of your organization. If there will be business affiliates who will also be “sellers” of the Technology, please enter their legal names.

Item R3. Data Universal Numbering System (DUNS) Number

If your company has a nine-digit DUNS number, enter it here. If your company does not have a DUNS number, you do not need to provide one.

Item R4. North American Industry Classification System (NAICS) Code

NAICS Codes can be found in the official 2002 US NAICS Manual North American Industry Classification System—United States, 2002, available from the National Technical Information Service, (800) 553-6847 or (703) 605-6000), or directly from http://www.census.gov/epcd/www/naics.html.

Point-of-Contact Information

Item R5. Primary Point of Contact

Enter the name of the individual who will serve as the primary point of contact for interactions between your organization and OSAI. Provide a business address and telephone information for this person. OSAI prefers not to use personal or home contact information unless no other contact information is available. Include area codes and any non-U.S. country codes in telephone and fax numbers. If you wish to permit OSAI to correspond with this individual by e-mail, enter a valid e-mail address in the space provided.

The Applicant’s point of contact may be any person you desire to coordinate your application and may include counsel, a representative of management, a technical expert or any other person you consider appropriate for this purpose.

Item R6. Secondary Point of Contact

Enter the name and contact information for an alternate point of contact in your organization. OSAI will attempt to contact this person only if it is unable to reach the primary point of contact identified in item R5.

DHS Form 10010 (10/06)