Attachment_0002_--_AMSTA-AR_Form_1350_Technical_Data_Request_Questionnaire_(2).pdf

W15QKN-17-R-0214 Attachment 0002

Technical Data Request Questionnaire

This Questionnaire is designed to provide Government personnel with a detailed description of the requested technical data and adequate information to permit compliance with Department of Defense (DOD) Directive 5230.25. Please answer each question completely and in detail, thereby providing the Government with all the information necessary to process your request promptly. Failure to provide a complete response to all questions and/or abstract answers, such as "unknown", "not available", etc. may unnecessarily delay the processing of your request and/or result in denial of release.

1. Name of Requester:

Address:

Point of Contact Regarding this Request:

Telephone Number: Area Code: Extension

Department of Defense Certification/Registration Number:2.

(Assigned after submittal and approval of DD Form 2345, Export-Controlled Technical Data Agreement.)

Requester must submit proof of a legitimate business interest in the information requested.

Examples of such are submission of your Federal Supply Code for Manufacturere (FSCM), or Contractor and Government Entity (CAGE) Code or Federal Supply Code for Non-Manufacturers

(FSCNM):

3.

AMSTA-AR Form 1350, 3 Feb 97 Replaces AMSMC Form 1350, 1 Feb 86, which may not be used. ARDEC V 1.0

Is Requester a citizen of the United States?:4.

If "No", specify citizenship:

Yes No

Has Requester obtained from the United States Department of State the appropriate approvals under the International Traffic In-Arms Regulations?

5.

If "Yes", provide evidence of same below; if "No", explain below:

Yes No

6. Please identify the solicitation and drawing package number (as given in Section C of the

Solicitation) under which this technical data is being requested:

(W15QKN): Drawings Package:

Any technical data which may be released will be subject to the terms and conditions as given in the solicitation and the following:

7.

a. Should the United States Government inadvertently deliver to the Requester any documents containing restrictive legends (prohibiting use by the Requester), then the Requester agrees to promptly return such documents without using, copying, or disclosing same to third parties.

b. An export license must be obtained before the said data, or any portion thereof, or any items made in accordance therewith, are exported.

I certify that all statements made by me are true and correct to the best of my belief and I agree to all terms and conditions of the release.

8.

On:

(Day, Month, Year)

Signed on behalf of:

(Name of Firm)

By:

(Typed or Printed Name and Title)

AMSTA-AR Form 1350, 3 Feb 97 Replaces AMSMC Form 1350, 1 Feb 86, which may not be used. ARDEC V 1.0