RAR_Form_-_Template.docx

US Mission Lima, Peru– Local Guard Program Restricted Access Request

RESTRICTED ACCESS REQUEST - LOCAL GUARD PROGRAM

U.S. MISSION LIMA,PERU

SAQMMA17R0093

THIS FORM MUST BE FILLED OUT IN ITS ENTIRETY*. ANY INFORMATION NOT SUPPLIED WILL RENDER THIS REQUEST INVALID.

1. Requester Information

a. Company Name _____________________________________________________

b. Company Address ___________________________________________________

c. DUNS No. or CAGE CODE ___________________________________________

d. Point of Contact _____________________________________________________

e. Telephone No _______________________________________________________

f. E-mail Address ______________________________________________________

2. My interest in this project is as a (please check one):

a. a. [ ] Prime Contractor

b. b. [ ] Joint Venture Participant

c. c. [ ] Other (please specify) ___________________________________________

3. I, the undersigned, agree that I will safeguard this information in accordance with the following distribution restriction statement:

RESTRICTED DISTRIBUTION AGREEMENT

Distribution authorized to legitimate bidders only, contains technical or operation information.

THESE RESTRICTED ACCESS DOCUMENTS MAY NOT BE DUPLICATED NOR IS ANY SECONDARY DISTRIBUTION OF DOCUMENTS AUTHORIZED. ANY AND ALL FIRMS WISHING TO VIEW ANY PART OF THESE DOCUMENTS MUST REGISTER WITH FEDBIZOPS, COMPLETE AND SIGN THIS FORM, AND HAVE THEIR REQUEST APPROVED BY THE GOVERNMENT. DATA SHALL BE KEPT IN A LOCKED DESK, LOCKED FILING CABINET, OR LOCKED ROOM WHEN NOT IN USE. UPON TERMINATION OF USE, THE HARDCOPY PRINTS AND ANY ELECTRONIC MEDIA SHALL BE DESTROYED BY SHREDDING THE PRINTS AND FORMATTING THE ELECTRONIC MEDIA. UPON TERMINATION OF USE, ALL MEDIA SHALL BE REMOVED FROM ANY COMPUTERS.

DO NOT COPY, SCAN OR POST ANY PART OF THESE BIDDING DOCUMENTS ON THE INTERNET.

Printed Name:____________________________ Signature:______________________________________

*Completed form may be e-mailed to GuilloryYR@state.gov or LocalGuardBranchCO@state.gov or faxed to 571-345-2356 Restricted Access Request Page 1