Sensitive_Security_Information_Acknowledgement_Form.docx
DOCX document 20 KB Posted
- Attached to
- Powdered Activated Carbon
- Solicitation number
- IFB-26-0248
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Sensitive Security Information Acknowledgement Form issued by the City of Phoenix Aviation Department for use in connection with a powdered activated carbon procurement contract. The form serves as a template to ensure that individuals and companies receiving security-sensitive documents understand the restrictions governing their use and disclosure. The powdered activated carbon contract is a five-year agreement commencing on or about May 1, 2026, with the effective date upon City Council award and signature by the City Clerk's department, whichever is later. The solicitation is conducted through the City's Procurement Portal, and interested offerors should contact the listed procurement officer with questions.
Signatories to the Sensitive Security Information Acknowledgement Form acknowledge receipt of documents containing information controlled under 49 C.F.R. Parts 15 and 1520 and agree to limit disclosure only to persons with a legitimate "need to know" as defined in those regulations. Unauthorized release of such information may result in civil penalties or other legal action. Upon the earlier of the company's completion of its need to review and use the documents or the contract end date, all documents must be destroyed in compliance with applicable federal regulations. The form requires the authorized company representative to provide signature, printed name, title, phone number, and complete address information.
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Text version
EXHIBIT __
City of Phoenix Aviation Department Sensitive Security Information Acknowledgement Form
The documents entitled [fill in document title(s)] (“Documents”) to be used as part of the [fill in project name] contain Sensitive Security Information that is controlled under 49 C.F.R. Parts 15 and 1520. These documents may only be disclosed to persons who have the requisite “need to know”, as defined in 49 C.F.R. Parts 15 and 1520. Unauthorized release of this information may result in civil penalty or other action. For U.S. government agencies, public disclosure is governed by 5 U.S.C. 552 and 49 C.F.R. Parts 15 and 1520.
I acknowledge, on my behalf and that of my company, the above statement and agree to destroy the [fill in document title(s)], in compliance with 49 C.F.R. Parts 15 and 1520, upon the earlier of our company’s completion of our need to review and/or use the Documents or no later than [fill in current contract end date].
NAME OF COMPANY
AUTHORIZED REPRESENTATIVE PRINTED NAME
AUTHORIZED REPRESENTATIVE’S SIGNATURE
| ______ | ||
| TITLE | PHONE NUMBER |
ADDRESS CITY, STATE AND ZIP CODE
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