Form ITA-4149P SELF-CERTIFYING AN ORGANIZATION'S COMPLIANCE WITH THE SA

OMB Control No. 0625-0239

Expiration Date: XX/XX/XXXX

The OMB clearance number cited above does not refer to an organization’s Safe Harbor application number and the expiration date provided above does not refer to the date by which an organization must recertify in order to maintain its certification status. The information provided above refers exclusively to the Safe Harbor self-certification form’s OMB Control Number (n.b., that clearance number and that expiration date appear at the top of all pending Safe Harbor self-certification submissions and existing Safe Harbor records).

SELF-CERTIFYING AN ORGANIZATION'S COMPLIANCE WITH THE SAFE HARBOR FRAMEWORK(S)

To expedite the self-certification process, please prepare the required information before completing this form (See Information Required for Certification).

If you have any difficulty completing this form or have questions concerning the Safe Harbor self-certification process, please contact the Safe Harbor Team at the International Trade Administration, U.S. Department of Commerce (E-mail: [email protected]; Tel.: 202-482-4936 or 202-482-1512).

Public reporting for this collection is estimated to be 40 minutes per response (i.e., per self-certification submission) including the time to review the instructions, complete, and submit 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: To save, please click on the Save button at the bottom of the page. Please save periodically as you complete the form; doing so will minimize, if not prevent, the loss of any information entered into the form should an unexpected system error occur. In addition, saving periodically will prove useful should you find that you require additional time to complete the application or otherwise choose to complete the application at some other time.



ORGANIZATION INFORMATION

Organization Name:
Address:	* Required
City:	* Required
State:	* Required
Zip:	Zip code must be of the form 20230 * Required
Phone:	* Required * Enter phone number as 999-999-9999.
Fax:	* Enter fax number as 999-999-9999.
Website:	* Required

ORGANIZATION CONTACT (i.e., individual or office handling all issues concerning your organization’s compliance with the Safe Harbor Framework(s), including complaints, access requests, and maintenance of your organization’s certification status)

Contact Office:	* Required Maximum 100 characters
Contact Name:	Maximum 100 characters
Contact Title:	Maximum 100 characters
Contact Phone:	* Required * Enter phone number as 999-999-9999.
Contact Fax:	* Enter fax number as 999-999-9999.
Contact Email:	* Required * Not a valid e-mail address.

CORPORATE OFFICER (i.e., individual certifying your organization’s compliance with the Safe Harbor Framework(s))

Corporate Officer Name:	* Required Maximum 100 characters
Corporate Officer Title:	* Required Maximum 100 characters
Corporate Officer Phone:	* Required * Enter phone number as 999-999-9999.
Corporate Officer Fax:	* Enter fax number as 999-999-9999.
Corporate Officer Email:	* Required * Not a valid e-mail address.

DESCRIPTION OF YOUR ORGANIZATION’S ACTIVITIES WITH RESPECT TO PERSONAL INFORMATION RECEIVED FROM THE EU/EEA AND/OR SWITZERLAND (i.e., a brief summary of what, why, and when such personal information is received)
* Required
Please limit to 8000 characters or less.
Maximum 8000 characters

DESCRIPTION OF THE ORGANIZATION'S PRIVACY POLICY FOR PERSONAL INFORMATION

Please enter the effective date of your organization's privacy policy: * Required
* Please enter a valid date.
Please provide the location of your organization's relevant privacy policy statement(s). Please note that with the exception of a privacy policy statement that exclusively covers your organization’s own human resources data (i.e., if such data is covered by your organization’s self-certification), all other relevant privacy policy statements must be made readily available on your organization’s public website(s) or uploaded hereto if your organization does not have a public website.

OR

Upload the privacy policy statement:
Upload only Word (.doc,.docx) document or PDF.

Please indicate the appropriate statutory body that has jurisdiction to hear any claims against your organization regarding possible unfair or deceptive practices and violations of laws or regulations governing your organization’s privacy practices:
* Required

Please list any privacy program(s) in which your organization is a member (e.g., a self-regulatory privacy program that adheres to the Safe Harbor Privacy Principles):
See FAQ 6

* Required (If not applicable, type NONE)

What is your organization's verification method (e.g., in-house or third party; if third party, please specify which one)? See FAQ 7
* Required

Which independent recourse mechanism(s) is(are) available to investigate unresolved complaints concerning your organization’s compliance with the Safe Harbor Framework(s) (e.g., a specific private sector developed dispute resolution mechanism that incorporates the Safe Harbor Framework(s) and/or the EU and/or Swiss data protection authorities)? See U.S.-EU Safe Harbor Framework FAQ 11 and U.S.-Swiss Safe Harbor Framework FAQ 11. Please note that the Federal Trade Commission (FTC) does not function as an ‘independent recourse mechanism’ under the Safe Harbor Framework(s).
* Required
Please limit to 8000 characters or less.
Maximum 8000 characters

What ‘personal data’ (i.e., any data about an identified or identifiable individual) ‘processed’ (i.e., whether or not by automatic means; e.g., collection, recording, organization, storage, adaptation or alteration, combination, retrieval, consultation, use, disclosure by transmission, dissemination, etc.) by your organization within the scope of the Safe Harbor Framework(s) is covered under your organization’s self-certification (e.g., organization, client, customer, visitor, clinical trial data, etc.)? Please indicate whether or not the data covered includes manually processed data.
* Required
Maximum 400 characters

Does your organization plan to cover ‘organization human resources data’ (i.e., personal information about your organization’s own employees, past or present, collected in the context of the employment relationship) under its self-certification?
* Required

If your organization does plan to cover ‘organization human resources data’ (i.e., as defined above) under its self-certification, then it must agree to cooperate and comply with the EU and/or Swiss data protection authorities (See U.S.-EU Safe Harbor Framework FAQ 5 and FAQ 9 , and U.S.-Swiss Safe Harbor Framework FAQ 5 and FAQ 9 ). Please note that even if your organization does not plan to cover ‘organization human resources data’ under its self-certification, it may nevertheless voluntarily agree to cooperate and comply with the EU and/or Swiss data protection authorities. Does your organization agree to cooperate and comply with the appropriate data protection authorities?
* Required

Please select all of the countries listed below from which your organization receives or reasonably anticipates receiving personal information within the scope of the Safe Harbor Framework(s) that will be covered by your organization’s self-certification. Please note that selection of “Switzerland”, regardless of whether it is specifically selected or “All” countries are selected, will be interpreted as your organization’s self-certification of compliance with the U.S.-Swiss Safe Harbor Framework; and, failure to select any country will be interpreted as your organization’s self-certification of compliance with only the U.S.-EU Safe Harbor Framework).

Select All   None

Austria	Denmark	Hungary	Liechtenstein	Norway	Slovenia
Belgium	Estonia	Iceland	Lithuania	Poland	Spain
Bulgaria	Finland	Ireland	Luxembourg	Portugal	Sweden
Croatia	France	Italy	Malta	Romania	Switzerland
Cyprus	Germany	Latvia	Netherlands	Slovakia	United Kingdom
Czech Republic	Greece

Please select your organization’s appropriate industry sectors. (Select up to 4) * Required

Please select your organization’s level of sales:
Please select your organization’s number of employees:

Please print a copy of the completed form before proceeding any further, so that your organization can retain a copy of this self-certification submission.

Please click the Continue button, which is located immediately below, when you are ready to make your organization’s self-certification submission.