DHS10003 - Notice of License

OMB No. 1640-0001
Expires: 10/31/06

DEPARTMENT OF HOMELAND SECURITY

NOTICE OF LICENSE OF QUALIFIED ANTI-TERRORISM
TECHNOLOGY
L1. Seller Name:
L2. QATT Information
L2.1. QATT Name:
L2.2. QATT Application ID Number:
L3. Name of Licensee:
L3.1. Licensee Place of Incorporation:
L4. Method of License (choose one):
Exclusive
Non-Exclusive
L5. Date of Commencement of License:
L6. Terms of License:
L7. Provide a description of the license agreement including an affirmation that SAFETY
Act protections only attach to the Technology that is described in Exhibit A of the
licensor's letter of Designation or Certification, as applicable. Attach supporting
information as necessary. Indicate that the transferee is cognizant of the requirements to
meet the transferor's insurance requirements and any other special conditions which
might affect the deployment of the licensed technology.
L8. Provide information regarding the described licensing effect on the QATT's safety or
efficacy, or risk(s) associated with its deployment.

DHS FORM 10003 (10/06)

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DECLARATION FOR WRITTEN SUBMISSIONS
I declare, to the best of my knowledge and belief, that the information provided in response to the
questions set forth in this Application for SAFETY Act liability protections is true, factual, and correct,
and that I am an authorized agent of the Applicant.
Prepared By:

Title (if applicable):

Signature:

Date:

/

/20

The signature of the Preparer must be notarized below:
State of:
Subscribed and sworn before me this

County of:

day of

Notary Public:
My Commission Expires on:

Privacy Act Notice: DHS will use the information on Form OMB 1640-0001 to determine eligibility for the requested
SAFETY Act protections. This information is to be regarded as “SAFETY Act Confidential” and protected from
release pursuant to §25.10 of the Regulations Implementing the SAFETY Act of 2002, 6 C.F.R., Part 25, 71 Fed. Reg.
33147, 33159 (June 6, 2006).
Burden Statement: Public reporting burden for this form is estimated at 2.5 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and checking the collection forms. This effort is necessary to obtain or retain a benefit, as required by Public Law
107-296, Subtitle G of Title VIII of the Homeland Security Act of 2002. Written comments regarding this form should
be submitted to the Office of SAFETY Act Implementation, Department of Homeland Security, Science and
Technology Directorate. Comments should be addressed and mailed to Silvia Cabrera, Acting Director OSAI,
Department of Homeland Security/ Science and Technology Directorate, Washington, D.C. 20528, or sent via
electronic mail to [email protected], or faxed to (703) 575-8416.

DHS Form 10003 (10/06)

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