Self-Certifying an Organiization's Adherence to the Safe

Safe Harbor - Application

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Expires:
04/30/2011

OMB clearance number 06250239

SELF - CERTIFYING AN
ORGANIZATION'S ADHERENCE TO THE SAFE HARBOR

To expedite the certification process, prepare the required information before completing this form.
( See Information Required for Certification )
If you have any difficulty completing this form or have any other questions concerning the Safe Harbor
self-certification process, please contact Damon C. Greer at the International Trade Administration,
Department of Commerce, [email protected], or 202-482-5023.
Public reporting for this collection is estimated to range from 20-40 minutes per response, including the
time for reviewing instructions, and completing and reviewing the collection of information. All
responses to this collection of information are voluntary, and will be provided confidentially to the
extent allowed under the Freedom of Information Act. Notwithstanding any other provisions of law, no
person is required to respond to nor shall a person be subject to a penalty for failure to comply with a
collection of information subject to the requirements of the Paperwork Reduction Act unless that
collection of information displays a current valid OMB Control Number. Send comments regarding the
burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to the Reports Clearance Officer, International Trade Administration, Department of
Commerce, Room 4001, 14th and Constitution Avenue, N.W., Washington, D.C. 20230.

Note: Please save the application by clicking the Save Button in case you
required more time to complete the application or what to complete the
application at some other time.
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ORGANIZATION INFORMATION
Organization Name:
Address:
City:
State:

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Safe Harbor - Application

Zip:
Phone:
Fax:
Website:

ORGANIZATION CONTACT INFORMATION (FOR HANDLING OF COMPLAINTS, ACCESS
REQUESTS, AND ANY OTHER ISSUE ARISING UNDER THE SAFE HARBOR)
Contact Office:

Maximum 100 characters

Contact Name:

Maximum 100 characters

Contact Title:

Maximum 100 characters

Contact Phone:
Contact Fax:
Contact Email:

CORPORATE OFFICER WHO IS CERTIFYING THE ORGANISATION'S ADHERENCE TO THE SAFE
HARBOR FRAMEWORK

Corporate Officer Name:

Maximum 100 characters

Corporate Officer Title:

Maximum 100 characters

Corporate Officer Phone:
Corporate Officer Fax:
Corporate Officer Email:

DESCRIPTION OF THE ACTIVITIES OF THE ORGANIZATION WITH RESPECT TO
PERSONAL INFORMATION RECEIVED FROM THE EU

Maximum 8000 characters

DESCRIPTION OF THE ORGANIZATION'S PRIVACY POLICY FOR
PERSONAL INFORMATION
Please enter the effective date of your organization's privacy policy:
Please provide the location of your organization's privacy policy:
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Safe Harbor - Application

http://

OR
Browse...

Upload the privacy policy:

Please indicate the appropriate statutory body that has jurisdiction to hear any claims against the
organization regarding possible unfair or deceptive practices and violations of laws or regulations
governing privacy:
Select Statutory Body

List any privacy programs in which your organization is a member for safe harbor purposes:
See FAQ 6

What is your organization's verification method e.g., In-house, Third Party. See FAQ 7

What independent recourse mechanism(s) is(are) available to investigate unresolved complaints (e.g.,
private sector developed dispute resolution mechanisms that incorporate the safe harbor framework or
EU data protection authorities. See FAQ 11

Maximum 8000 characters
What personal data processed by your organization is covered by the safe harbor? (e.g., off-line, online, manually processed data, human resources data)
Maximum 400 characters
Do you plan to cover human resources data?
--Select--

If yes, you need to agree to cooperate and comply with the European Data Protection Authorities (See
FAQs 5 & 9 ). Do you agree to cooperate and comply with the European Data Protection Authorities?
--Select--

Which EU/EEA Countries do you receive information from? (Select all that apply)
Select All

None

Austria

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Estonia

Hungary

Liechtenstein

Norway

Slovakia

Safe Harbor - Application

Belgium

Finland

Iceland

Lithuania

Poland

Spain

Bulgaria

France

Ireland

Luxembourg

Portugal

Sweden

Cyprus

Germany

Italy

Malta

Romania

Switzerland

Greece

Latvia

Netherlands

Slovenia

Czech
Republic

United
Kingdom

Denmark
Please select your appropriate Industry Sectors. (Select up to 4)

Please select the appropriate level of sales?:

Enter Sales Amount

How many employees does your organization have?:

Enter Number of Employees

Please print out your completed form now to verify that the information provided is correct and to
retain a copy for your files.
If you are ready to submit the self certification for your organization simply click the Continue button
below.
Continue

Save

Cancel

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