DHS Form 10004 SAFETY ACT BLOCK CERTIFICATION APPLICATION

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

Department of Homeland Security

Science and Technology Directorate

SAFETY ACT BLOCK CERTIFICATION APPLICATION

The Secretary may issue Block Certifications at his discretion for anti-terrorism technologies that meet established performance standards or defined technical characteristics. Sellers of Technologies that are the subject of a Block Certification may submit a streamlined application to be afforded the liability protection available under the SAFETY Act. Block Certification will be published on the SAFETY Act Web site (http://www.safetyact.gov).

Each Block Certification may set forth particular terms and conditions that should be addressed in the accompanying application to be used in applying for SAFETY Act protection pursuant to a particular Block Certification.

(Block Certification 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 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 10004 (10/06)

SAFETY ACT BLOCK CERTIFICATION APPLICATION

APPLICATION TYPE

BC1. Type of Application.

I am responding to an announced Block Certification. Reference:

Date issued: Technology Name: Resubmission of a Previous Application for an announced Block Certification.

Previous Application ID #:

Reference:

Date issued: Technology Name:

REGISTRATION INFORMATION

BC2. Registration Status (choose one):

I am updating or correcting previous registration information. My previously provided registration information is still accurate.

BC3. Name of Seller:

BC4. Company Description. Provide an overview of your company, including a description of your business.

BLOCK CERTIFICATION

Respond to all items in this section in one attachment to this application. Additional supporting material can be attached as an appendix to your application.

BC5. If any other corporate entity or entities should be identified as an authorized Seller of the subject Technology in addition to the firm identified in the response to BC3. above, please identify each entity and the place in which it is organized.

BC6. Provide the Earliest Date of Sale of the Technology for which you are requesting SAFETY Act coverage.

BC7. Identify the Block Certification to which you are responding by noting the name of the Block Certification and the date it was issued. Reference any special terms or conditions presented in the referenced Block Certification.

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.

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

BC8. Submit information demonstrating your Technology’s compliance with the technical specifications of the Block Certification.

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.

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

BC9. Submit information demonstrating your Technology’s compliance with the terms and conditions of the referenced Block Certification.

BC10. Submit any other information concerning the Technology which may be helpful to the Department in consideration of this application.

DECLARATION FOR WRITTEN SUBMISSIONS

Instructions for Completing Block Certification Application Form:

Application Type

Item BC1. Type of Application

If your application is in response to an announced Block Certification, check the appropriate box and follow the instructions set forth in the particular Block Certification announcement.

Registration Information

Item BC2. Registration Information

Please check the appropriate box relating to your registration status.

Item BC3. Name of Seller

Please provide the legal name of the Seller/Applicant.

Item BC4. Company Description

The purpose of this item is to help the Department recognize potential conflicts of interest and avoid disclosing your application information to inappropriate evaluators. The Department is committed to protecting your sensitive business data from improper disclosure.

Provide a brief description of your company. When describing your company, focus on identifying any affiliates associated with your Technology (e.g., parent companies, subsidiaries, joint venture partners, holding companies, etc.).

Do not include any sensitive or proprietary information in this summary. If you wish to include information on substantially similar QATTs or provide information regarding who your major competitors are with respect to the subject Technology, you may do so.

Block Certification Item BC5. Seller

In certain instances, multiple corporate entities may appropriately be identified as a

Seller of the subject Technology. For instance, the Seller of the QATT could include a parent company as well as subsidiaries or other affiliates. Your response will be used to properly identify the Seller(s) of the QATT. If you would like multiple entities to be considered a Seller of the QATT, please clearly identify these firms and identify their respective place of incorporation.

Item BC6. Earliest Date of Sale

This information will be used to specify the Earliest Date of Sale of the QATT to which the Certification shall apply (note this date may be prior to the effective date of the Certification).

Item BC7. Identification of Block Certification

Please identify the Block Certification to which you are responding by noting the name of the Block Certification and the date it was issued. Reference any special terms or conditions presented in the referenced Block Certification.

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.

Item BC8. Compliance with Technical Merits

In order for the Under Secretary to extend SAFETY Act protections to your Technology, please provide sufficient information to demonstrate that your Technology complies with the technical merits of the reference Block Certification. Please be specific.

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.

Item BC9. Compliance with Terms and Conditions

Please demonstrate how your Technology complies with the terms and conditions stated in the referenced Block Certification. Please be specific and provide sufficient details.

Item BC10. Other Information

Please provide other information that may help the Department of Homeland Security as it considers your application. This may include information such as material demonstrating the Technology’s effectiveness, utility, and readiness for sale.

Additional Attachments

In the process of answering the questions above, you might find it useful to attach additional documents in support of your answers. These items can be included in your application by using the “Additional Attachments” feature. When answering the items above, it is appropriate to refer to attachments by name or number. Examples of common attachments might include, but are not limited to, the following: test reports demonstrating the effectiveness of the Technology, operating manuals, training manuals, project/program management plans, quality assurance plans, quality control plans, copies of test reports demonstrating effectiveness, results from pilot studies, testimonials from customers, and warranties.

Declaration for Written Submissions

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