DHS Form 10010 (10 REGISTRATION AS A SELLER OF ANTI-TERRORISM TECHNOLOGY

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

REGISTRATION AS A SELLER OF ANTITERRORISM TECHNOLOGY
ACTION
R1. Purpose of Registration (choose one)
Initial Registration
Updated or Corrected Registration Information

REGISTRATION DATA
R2. Seller Name:
R3. Data Universal Numbering System (DUNS) Number (if available):
R4. North American Industry Classification System (NAICS) Code (if available):
POINT-OF-CONTACT INFORMATION
R5. Primary Point of Contact:
Name:
Address:
State/Province:

Country:

Telephone No:

Fax No:

ZIP/Mail Code:

Email:
Yes:

E-mail Communication Authorized?:

No:

R6. Secondary Point of Contact (optional):
Name:
Address:
State/Province:

Country:

Telephone No:

Fax No:

ZIP/Mail Code:

Email:
E-mail Communication Authorized?:

DHS Form 10010 (10/06)

Yes:

No:

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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 5.5 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 10010 (10/06)

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