DHS Form 10004 (10 SAFETY ACT BLOCK CERTIFICATION APPLICATION

OMB No. 1640-0001
Expires: 10/31/06
DEPARTMENT OF HOMELAND SECURITY

SAFETY ACT BLOCK CERTIFICATION APPLICATION

APPLICATION TYPE
BC1. Type of Application:
I am responding to an announced Block Certification. Reference:
Date issued:

; Technology Name:

Resubmission of a Previous Application for an announced Block Certification.
Previous Application ID #:
Date issued:
; Technology Name:

REGISTRATION INFORMATION
BC2. Registration Status (choose one):
I am updating or correcting previous registration information.
My previously provided registration information is still accurate.

BC3. Name of Seller:
BC4. Company Description. Provide an overview of your company, including a description of your
business.

BLOCK CERTIFICATION
Respond to all items in this section in one attachment to this application. Additional supporting
material can be attached as an appendix to your application.

BC5. If any other corporate entity or entities should be identified as an authorized Seller of the subject
Technology in addition to the firm identified in the response to BC3.1 above, please identify each
entity and the place in which it is organized.

BC6. Provide the earliest date of sale of the Technology for which you are requesting to SAFETY Act
coverage.

BC7. Identify the Block Certification you are responding to by noting the name of the Block Certification
and the date it was issued. Reference any special terms or conditions presented in the referenced
Block Certification.

BC8. Submit information demonstrating your Technology's compliance with the technical specifications of
the Block Certification.

BC9. Submit information demonstrating your Technology's compliance with the terms and conditions of the
referenced Block Certification.

DHS Form 10004 (10/06)

Page 1 of 2

BC10. Submit any other information concerning the Technology which may be helpful to the Department in
consideration of this application.

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 6 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 10004 (10/06)

Page 2 of 2