DRAFT PWS Attachment M-1 - DD Form 2345 Technical Data Agreement.pdf

T56 PWS Attachment M-1 - Technical Data Agreement

MILITARILY CRITICAL TECHNICAL C

(Please read Agency Disclosure Notice and before completing this fo

ATA AGREEMENT

Vnstructions on back 'n.)

0MB No. 0704--0207 0MB approval expires Apr 30, 2011

MAIL THE ORIGINAL, COMPLETED COPY OF THIS FORM AND J

PROVINCIAL BUSINESS LICENSE, SALES TAX IDENTIFICATIOP

OF THE COMPANY TO:

U.S./CANADA J1

DLA LOGISTI

FEDERAL CENTER

BATTLE CR

COPY OF YOUR COMPANY'S INCORPORATION CERTIFICATE, STATE/

FORM OR OTHER DOCUMENTATION WHICH VERIFIES THE LEGITIMACY

!>INT CERTIFICATION OFFICE

CS INFORMATION SERVICE

74 WASHINGTON AVE., NORTH

EEK, Ml USA 49037-3084

1. TYPE OF SUBMISSION (X one) I a. INITIAL SUBMISSI ON b. REVISION c. 5-YEAR RENEWAL

2. ENTERPRISE OR INDIVIDUAL DATA (Referred to as a "certified 'contractor" upon acceptance of certification by the U.S./Canada - JCO)

a. NAME (Name of Enterprise or Individual) b. ADDRESS (Physical address, including P.O. Box if applicable)

c. NAME OF SUBSIDIARY/DIVISION/DEPARTMENT

d. CAGECODE

3. DATA CUSTODIAN

a. NAME OR POSITION DESIGNATION (See Instructions) b. TELEPHONE NUMBER (Include Area Code)

c. TITLE d. E-MAIL ADDRESS

4. DESCRIPTION OF RELEVANT BUSINES$ ACTIVITY (Print or ty, be)

5. AS A CONDITION OF RECEIVING MILITARILY CRITICAL TECJ, NICAL DATA, THE ENTERPRISE OR INDIVIDUAL CERTIFIES THAT:

a. CITIZENSHIP/RESIDENCY STATUS.

The individual designated either by name or position designation in Item 3 will act as custodian of the militarily critical technical data on behalf of the cont is a citizen or person admitted lawfully for permanent residence into:

(X (1) or (2)) who actor,

d. They will not provide access to militarily critical technical data to persons other than their employees or eligible persons designated by the registrant to act on their behalf unless such access is permitted by U.S. DoDD 5230.25, Canada's TDCR, or by the U.S. or Canadian Government agency that provided the technical data.

I (1) THE UNITED STATES I (2) CANADA

e. No person employed by the enterprise or eligible persons designated by the registrant to act on their behalf, who will have access to militarily critical technical data, is disbarred, suspended, or otherwise ineligible to perform on U.S. or Canadian Government contracts or has violated U.S. or contravened Canadian export control laws or has had a certification revoked under the provisions of U.S.

DoDD 5230.25 or Canada's TDCR.

b. The data are needed to bid or perform on a contract with any agency of the Government or the Canadian Government or for other legitimate business acti1 in which the contractor is engaged, or plans to engage.

µ.s.

ities

c. They (1) acknowledge all respcnsibilities under applicable U.S. expert centreI laws and regulations (induding the obligation, under certain circumstances, to an export license from the U.S. Government prior to the release of militarily crit technical data within the United States) or applicable Canadian export control I and regulations, and (2) agree not to disseminate militarily criticaJ technical dat manner that would violate applicable U.S. or Canadian export control laws and regulations.

bbtain cal aws a in a f, They are not themself debarred, suspended, or otherwise ineligible to perform on U.S or Canadian Government contracts, and have not violated U.S. or contravened Canadian export control laws, and have not had a certification revoked under the provisions of U.S. DoDD 5230.25 or Canada's TDCR.

6. CONTRACTOR CERTIFICATION

I certify that the information and certifications made by me are truE good faith. I understand that a knowing and willful false statement or (For U.S. contractors see U.S. Code, Title 18, Section 1001 and for C

, complete, and accurate to the best of my knowledge and belief and are made in this form can be punished by fine or imprisonment or both.

lanadian contractors see Section 26 of the Defense Production Act.)

a. TYPED NAME (LAST, First. Middle Initial) b. TITLE c, SIGNATURE d. DATE SIGNED

7. CERTIFICATION ACTION (For JCO Use Only)

a. CERTIFICATION ACCEPTED. This certification number, along witl a b. NUMBER c. EXPIRATION DATE statement of intended data use, must be included with each request to militarily critical technical data.

8. DOD OFFICIAL 9. CANADIAN OFFICIAL

a. TYPED NAME (LAST, First, Middle Initial) a. TYPED NAME (LAST, First, Middle Initial)

b. TITLE b. TITLE

c. SIGNATURE d. DATE SIGNED C. SIGNATURE d. DATE SIGNED

DD FORM 2345, MAR 2011 PREVIOUSIEDITION IS OBSOLETE. Adobe Professional 8 O

INSTRUCTIONS FOR

COMPLETING DD FORM 2345

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information is est mated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources. gathering and maintl:lining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or a,,y other aspect of this collection of information, including suggestions for reducing the burden. to the Department of Defense, Washington 11eadquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon. Washington, DC 20301-1155 (0704-0207). Respondents should be aware that notwithstanding any other provision of law. no person shall be subject to any pena ty for failing to comply with a collection of information if ii does not display a currently valid 0MB control number.

SPECll=IC INSTRUCTIONS

1. Mark only one box. Mark "REVISION" (of a previously accept d submission) to show revised information, such as addresses or business description. Mark "5-YEAR RENEWAL" in response to, renewal notice from U.S./Canada - JCO. When either the "REVISION" OR "5-YEAR RENEWAL" box is marked, enter your current Certification Number in Item 7.b.

2. a. For an enterprise, show full name of corporate parent; or institution. For an individual, show full name (LAST, First, Middle initial).

b. Enter the physical mailing address of the enterprise or individual making the certification. If a P.O. Box is used for mailing purposes. include street address as well.

c. Each corporate subsidiary or division that is to receive militar ly critical technical data must be certified separately. If not applicab .

so state.

3. Show the name, business telephone number (including area code). title of the individual and their e-mail address (optional) whD will receive militarily critical technical data and be responsible for ls further dissemination. A position designation may be used onlit when conditions described in Item 5.a. are prerequisites for holding that position.

4. Describe the business activity of the entity identified in Item 2 ih sufficient detail for the U.S. or Canadian Government agency controlling the data to determine whether the militarily critical technical data that you may request from time to time are reasonably related to your stated business activity. For example, state that you design and construct high-pressure, high volume hydraulic pumps for use in connection with aircraft control surfaces;

do not state simply "hydraulic pumps." Provide concise statemen s within the space provided.

5. If certifications 5.e. and 5.f. cannot be made, provide (on a separate sheet) a description of any extenuating circumstances that may give sufficient reason to accept your certification.

5. a. If the location of the entity identified in Item 2.a. is the United States, the individual named in Item 3 must be a U.S. citizen or a person admitted lawfully for permanent residence into the United States. If the location of the entity is in Canada, the individual named in Item 3 may be either a Canadian or U.S. citizen or a person admitted lawfully for permanent residence into Canada.

6. If Item 2 identifies an individual. that individual must sign. If Item 2 Identifies an Institution or a corporate entity, a person who can legally obligate the enterprise to a contract must sign.

7. CERTIFICATION ACTION.

a. ACCEPTED. The U.S./Canada - JCO has assigned the enterprise or individual identified in Item 2.a.. a Certification Number which will identify the individual or enterprise as a "certified contractor" as defined in U.S. DoDD 5230.25 or Canada's TDCR.

The acceptance is valid for a period of five years from the acceptance date unless sooner revoked under the provisions of U.S. DoDD 5230.25 or Canada's TDCR. If at any time a certified contractor is unable to adhere to the conditions under which a certification was accepted, the contractor's certification is considered void, and the contractor will either submit a revised certification or surrender all militarily critical technical data obtained under this agreement to the data controlling offices specified on the documents.

b. NUMBER. Certification Number (assigned by the JCO).

c. EXPIRATION DATE. Date Certification Number will expire

(assigned by the JCO).

LEGEND:

DoD = Department of Defense DoDD = Department of Defense Directive U.S.ICanada - JCO = United States/Canada Joint Certification Oce TDCR = Technical Data Control Regulations

Militarily Critical Technical Data= Unclassified technical data a$ governed by U.S. DoDD 5230.25 or Canada's TDCR.

DD FORM 2345 (BACK), MAR 2011