SCG_Request_Form.pdf

DARPA Broad Agency Announcement (BAA) Addendum Request

DARPA uses personal information (including Social Security numbers (SSNs)) to conduct record checks with other U.S. Government agencies to determine the identity, citizenship status, and eligibility of individuals seeking access to DARPA BAA Addendums. All requests for personal information are made under appropriate authority. Note that due to the risk of data loss or breach, requestors should consider applying appropriate technical safeguards to protect their personal information before transmitting this form electronically. Once received by DARPA, personal information will be subject to role-based access controls and safeguarded using appropriate physical, administrative, and technical protocols.

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. 301; 15 C.F.R. 730-774; 22 C.F.R. 120-130; 40 U.S.C. 1441; 41 C.F.R. 102-81.10 and 102-81.15; DoDD

1000.25; DoD 5200.08-R; DoD 5200.1-R; DoDD 5200.27; DoDD 5205.07; DoD 5400.1-R; E.O. 9397, as amended, SSN; and, E.O. 12977

PURPOSE: DARPA will use personal information to determine the identity/eligibility of individuals requesting a BAA Addendum.

ROUTINE USES: Department of Defense "Blanket Routine Uses," consistent with the Privacy Act of 1974 (5 U.S.C. 552a), and available at http://privacy.defense.gov/blanket_uses.shtml, apply to this collection. The information will be used by - and disclosed to - DARPA personnel, contractor employees, or other agents who require the information to determine eligibility to access a DARPA BAA Addendum. DARPA may also share the information with other government agencies as necessary to determine if adverse information exists on the individual requesting the BAA Addendum.

DISCLOSURE: Furnishing this information (including your Passport information and Social Security Number if applicable) is voluntary; however, failure to furnish the requested information may delay or prevent your request.

Requestor Data

Last Name: First Name: M.I.:

Current Nationality/Citizenship: U.S. Social Security Number:

Resident Alien Permit Number: Passport Number:

Company/Organization Data

Name:

Address 1:

Address 2:

City: State: Zip Code:

Business Phone:

Cage Code (if any):

U.S. Owned Non-U.S. Owned

BAA Information

DARPA BAA# and Title: Tech Office Sponsor:

DARPA Form 105, AUG 2014

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