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

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: 1640-0012

4. Expiration Date: 08/31/2010

5. Agency Form Number: DHS Form 10039 (12/07)

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).

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:

   1. 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.

   2. 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

   1. Use one copy of the letter to cover multiple members of your team, if needed.

   2. Optional: Insert the prefix appropriate to the researcher(s) (Dr., Ms, Miss, Mrs., Mr.)

   3. 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). You may also create a PDF of the signed document and email to the PCC ([email protected]).

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

_________________________

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	Years with Sponsoring Organization	Title	Signature Authority to Bind Org (Y/N)

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	__________________________	Phone	________________