Attachment_0003_-_AMSTA_1350_FORM.PDF

AMSTA-AR Form 1350, January 2011 ARDEC V 1.0

Technical Data Request Questionnaire

This Questionnaire is designed to provide Government personnel with a detailed description of the technical data being requested as well as adequate information to permit compliance with Department of Defense (DoD) Directives 5230.24 and 5230.25. Each question should be answered completely and in detail, thereby providing the Government with all the information necessary to satisfy the request for technical data 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 (including area code): ____________________________________________

2. U.S./Canada Joint Certification Office Certification Number: ____________________________ (Assigned after submittal and approval of DD Form 2345, Militarily Critical Technical Data Agreement)

3. Requester’s proof of legitimate business interest in the information requested. Examples of such are submission of Federal Supply Code (FSC) or Contractor and Government Entity Cage Code

(CAGE): _____________________________________________________________________

4. Is Requester a citizen of the United States? Yes ______ No ______

If “No”, specify citizenship: ______________________________________________________

5. Identify the solicitation and technical data number (i.e. Technical Data Package Number, Drawing Number or Specification Number) under which this technical data is being requested:

W15QKN: ____________________ Technical Data Number: ___________________

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

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

b. If the said data is governed by the Arms Export Control Act and the International Traffic in Arms Regulations (ITAR), registration with the Department of State, AMSTA-AR Form 1350, January 2011 ARDEC V 1.0

Directorate of Defense Trade Controls, is required prior to manufacture or export of the defense article or furnishing of the defense service made in accordance therewith, unless an exemption under the ITAR applies.

c. If the said data is governed by the Arms Export Control Act and the International Traffic in Arms Regulations (ITAR), an export license must be obtained from the Department of State, Directorate of Defense Trade Controls, before the said data, or any portion thereof, or any items made in accordance therewith, are exported, unless an exemption under the ITAR applies.

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.

Signed on behalf of: __________________________________________________________________________________________ (Name of Firm)

On: __________________________________________________________________________________________ (Day, Month, Year)

By: __________________________________________________________________________________________ (Typed or Printed Name and Title)