Application for Safety Certification

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

DEPARTMENT OF HOMELAND SECURITY

Application for SAFETY Certification

APPLICATION TYPE
C1. Type of Application. This application is a(n) (choose one):
Initial Application Filing for a Certification, please provide
Designation Application ID #:
Resubmission of a Previous Application for Certification, please
provide Designation Application ID #:
EXPEDITED REVIEW
C2. Request for Expedited Review
In its discretion, the Department may identify categories of anti-terrorism
Technologies for which expedited processing may be granted. For example, the
Department may conduct expedited processing for applications that are the subject
of a pending or past Federal, State or local procurement, that addresses a particular
threat, that involve particular types of anti-terrorism Technologies or for other
reasons. Depending on the nature of the procurement, this may substantially
expedite and simplify the application process. If you are requesting expedition
review, please specify the basis for such request, including, if applicable,
information concerning an ongoing procurement. Such information should include
the following.
a. The name of procuring organization;
b. Contact information for the relevant government procurement official;
c. The related Request for Proposal (RFP) number or other official
identifier of the procurement, if available; and
d. Upcoming deadlines relating to the procurement (e.g., submission
deadline, decision/contract award, etc.).
Please note if your application falls under a published DHS Notice of Expedited
Processing and provide the referance number for such notice and a brief
statement as to why your application falls within the scope of the Notice of the
Expedited Processing. If you wish to provide other bases for expedited
processing please specify.
REGISTRATION INFORMATION
I am updating or correcting previous registration information.
My previously provided registration information is still accurate;
C3. Seller Name:
DHS Form 10007 (10/06)

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CERTIFICATION
Respond to all items in this section in one attachment to this application. Additional
supporting material may be attached as an appendix to your application.
C4. Performs as Intended. Define what it means for your Technology to perform
as intended, and provide information and/or data establishing that your
Technology performs as intended. This information may be the same as or in
addition to information provided for an Application for SAFETY Act
Designation.
C5. Conforms to Seller's Specifications. Describe the processes and procedures you
use to ensure that each sale of your Technology conforms to the applicable
specifications. If your Technology was or is involved in a government
procurement, acceptance of the Technology by the government and related
testing may be highly relevant here. Provide available documentation
demostrating that your Technology conforms to established specifications.
C6. Safe for use as intended. Provide available analyses evidencing that the
Technology is safe for use as intended. Please note any known or suspected
hazards or safety risks associated with your Technology. Please provide safety
and hazard analyses for your Technology
ADDITIONAL ATTACHMENTS
Provide additional supporting documentation
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:

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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 3.5 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 10007 (10/06)

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