Form 10039 (12/07) 10039 (12/07) Authorization Letter Data Provider

OMB No. 1640-New
Expires: TBD
DHS PREDICT Authorization Letter for Data Provider Form
Cover Sheet
1. Department Name: Department of Homeland Security
2. Component/Agency Name: Science and Technology Directorate
3. OMB Control Number: 1640-New
4. Expiration Date: TBD (Three years from approval date)
5. Agency Form Number: TBD
6. Name of Form: Authorization Letter for Data Provider
7. Purpose of Form: Required Form Letter to be filled out by sponsoring
organization to allow user to serve as a Data Provider for the PREDICT system
8. How to submit: Sign and fax to the PREDICT Coordinating Center, RTI
International, Attn: Renee Karlsen, 866.835.0255 (toll free).

3

COVER LETTER
AUTHORIZATION LETTER FOR DATA PROVIDER

READ THESE INSTRUCTIONS CAREFULLY
BEFORE PROCEEDING
Thank you for your interest in joining the PREDICT community as a Data Provider. In
order for your application to be considered, you must have a supervisor or other official,
who has the authority to sign on behalf of your organization, execute the attached
Authorization Letter. Please be sure to provide these instructions along with the
Authorization Letter template when requesting a signature. The completed and signed
Authorization Letter must be received and approved by the PREDICT Coordinating
Center (PCC) before your application for an account as a Data Provider can be
considered.
Directions:
1.
Print this letter on your institution’s letterhead. You may do this in two ways:
a. Cut and paste the text of the letter into your word processing program so you can
fill in the information requested using your institution’s letterhead. Once you
have inserted the information, you can save and print the letter. Note: you will
need to adjust the formatting for the word processing program you are using.
b. Fill in the form within the PDF. The top margin is about 1.5 inches to
accommodate letterhead. Print the letter on your institution’s letterhead.
2.
Fill in appropriate names, dates, and other information where indicated with the
requested information. Do not omit any of the requested information or your
application will be rejected
a. Use one copy of the letter to cover multiple members of your team, if needed.
b. Optional: Insert the prefix appropriate to the researcher(s) (Dr., Ms, Miss, Mrs.,
Mr.)
c. Spell out the name of your company, organization, and/or title. Do not
abbreviate.
3.
Print the Authorization Letter.
4.
Sign and fax the Authorization Letter to the PREDICT Coordinating Center, RTI
International, Attn: Renee Karlsen, 866.835.0255 (toll free).

Questions regarding your application may be directed to the PREDICT Coordinating
Center, at [email protected].

PREDICT_AuthorizationLtr_DP_v1.0

11/26/2007

_________________________
Today’s Date

RTI International, Inc.
Attn: Renee Karlsen
PREDICT Coordinating Center
PO Box 12194
Research Triangle Park, NC 27709-2194
SUBJECT: Application for access to the PREDICT portal as a Data Provider.

Dear Ms. Karlsen:
I am writing on behalf of the staff named below to apply for access to the PREDICT
portal website as a Data Provider, with the portal privileges accorded to Data Providers. I
understand that a letter of authorization from a Sponsoring Institution is one of the
required elements of a successful application, and this letter is intended to serve that
purpose.
By this letter, I am confirming on behalf of myself and my organization,
___________________________________ that: (Fill in all information and sign below):
1. This letter is being sent on behalf of the following staff (Applicant(s)):

Full Name

PREDICT_AuthorizationLtr_DP_v1.0

Years with
Sponsoring
Organization

Title

Signature
Authority to
Bind Org (Y/N)

11/26/2007

2. All named Applicant(s) are currently affiliated with this organization and serve(s)
in the capacity listed in Section 1.
3. Applicant(s) is/are an employee(s) or person(s) affiliated with this organization and
is/are in good standing with our organization.
4. Applicant(s) has/have authority to provide data to the PREDICT project.
5. I, or my successor in my role, will inform the PCC (a) if any of the Applicants
listed in Section 1 leave our organization, or (b) if their affiliation with this
organization changes in such a manner as to eliminate or call into question their
authority to upload data or have access to the PREDICT portal.
As a member of the cyber security research community, this organization appreciates the
importance of this work, and we are please to assist PREDICT as a Data Provider.
Should you have need for further information, please contact me.
Very truly yours,
Print Name:

____________________________________________________

Signature:
Title,
Position:

____________________________________________________

Email

PREDICT_AuthorizationLtr_DP_v1.0

____________________________________________________
__________________________

Phone

________________

11/26/2007