DHS Form 10009 (10 REQUEST FOR PRE-APPLICATION CONSULTATION

DEPARTMENT OF HOMELAND SECURITY

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

REQUEST FOR PRE-APPLICATION CONSULTATION

SELLER INFORMATION
P1. Seller Name:
P1.1 Description of Seller. Please provide an overview of your company,
including place of incorporation and major affiliates of subsidiaries.

P2. Non-proprietary Summary
P2.1 Name of your Technology:
P2.2 Technology Description. Provide a non-proprietary overview of your
Technology.

P3. Detailed description of your Technology. In an attachment, please provide a detailed
description of your Technology and summarize your Technology's qualifications for
SAFETY Act Designation.
P4. Past and anticipated sales. Note: It may be vary important and could significantly

expedite your eventual application if your Technology has been acquired or utilized
(or is subject to an ongoing

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procurement) by the military, a Federal government agency, or a state, local or foreign
government entity.
Who has purchased, utilized or plans to purchase your Technology? (choose all that apply.)
Federal governement (Agency:

Approximate Date:

)

State governement (State:

Approximate Date:

)

Local governement (City/County:

Approximate Date:

)

Commercial organization (Name:

Approximate Date:

)

Foreign government (Name:

Approximate Date:

)

Other (Name:

Approximate Date:

)

P5. Readiness for Sale. If your Technology has not previously been sold , provide an
estimate of when it will be available for sale.
Immediately available for sale
Expected to be available for sales with in

months. (Fill in the blank.)

P6. Effectiveness
How do you know that your Technology is effective? What kinds of deployment
information, test Results, independent studies, or other corroborative information
could you provide as part of a full Application to support the utility and effectiveness
of your Technology? In an attachment, provide a summary of the available
information supporting the safety and effectiveness of your Technology. Please
indicate any deployments for military or governmental customers. It may be
very important and could significantly expedite your eventual application if your
Technology has been acquired or utilized (or is subject to an ongoing procurement) by
the military, a Federal government agency, or a state, local or foreign government
entity.

P7. Liability Considerations
In an attachment, please identify the types of potential terrorist activity the
Technology is intended to counter. Please describe, to the extent practicable, the scope
of damage, loss of life, or other harm that could result from such terrorist activity.
Please describe how the Technology has been deployed to date or will be deployed in
the future should SAFETY Act Designation be issued.

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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 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.

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