Form DD 3067-5 DD 3067-5 Science, Mathematics & Research for Transformation (SMAR

Science, Mathematics & Research for Transformation (SMART) Scholarship
Media Release
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 4093, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 10 U.S.C. 133a, Under
Secretary of Defense for Research and Engineering; DoD Directive 5137.02, Under Secretary of Defense for Research and Engineering (USD(R&E)); DoD
Instruction 1025.09, Science, Mathematics, and Research for Transformation Defense Education Program.
PURPOSE: To obtain permission from SMART Scholars to use their image or visual likeness, name, and voice in publications and/or other productions for the
purposes of performing outreach, recruiting, and marketing related to the SMART Scholarship Program.
ROUTINE USES: While the information requested on this form is primarily intended to be used internally, in certain circumstances it may be necessary to
disclose this information externally, pursuant to 5 U.S.C. 552a(b)(3), including: to contractors, grantees, experts, consultants, students, and others performing or
working on a contract, service, grant, cooperative agreement, or other assignment for the Federal Government when necessary to accomplish an agency
function, or, to academic institutions for the purposes of providing progress reports for applicants and participants. A complete list of routine uses may be found in
the applicable Privacy Act System of Records Notice, DUSDA 14, Science, Mathematics, and Research for Transformation (SMART) Information management
System, found at https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DUSDA-14.pdf?ver=KO2ZkLWhxB3QCZoRTElMFA%3d%3d
DISCLOSURE: Voluntary.
The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense,
Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any
other provisions of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB
control number.
INSTRUCTIONS: Awardees of a SMART Scholarship read and sign the release statement below.
I, the undersigned, hereby grant the Department of Defense and/or its agents, employees, contractors, and/or assignees permission to use, adapt, modify,
reproduce, distribute, publicly perform, and/or display, in any form now known or later developed, my image or visual likeness, my name, my voice, and
information related to my experience with SMART, including, but not limited to, the dates of my participation, the name and location of the academic institution for
which I receive or received funding, the benefits and/or the monetary value of the benefits I received under SMART, the degree I am pursuing or have earned,
location and job description of internship and/or post-graduation employment, mentor experience, and general statements relating to working for the Federal
Government (collectively the “Information”) throughout the world by incorporating the Information into publications, catalogues, brochures, books, magazines,
photo exhibits, motion picture films, presentations, internet sites, blog posts, social media content, other media, and/or commercial, informational, educational,
advertising, or promotional materials (collectively the "Works").

NEEDS DD67

I hereby release, indemnify, hold harmless, and defend SMART and/or its agents, employees, licensees, and/or assignees from any and all claims, I or any third
party may have now or in the future for invasion of privacy, right of publicity, copyright infringement, defamation, and/or any other cause of action arising out of
the use, exploitation, reproduction, adaption, distribution, broadcast, performance, or display of the Information. I hereby waive any and all rights to inspect and/
or to approve any and all of the Works that may be created using the Information. I hereby waive any and all claims or potential claims related to the use(s) to
which the Information may be applied. The Information may be used at the sole discretion of SMART and/or its agents, employees, licensees, and/or assignees,
with or without my name or with a fictitious name, and with fictitious or accurate biographical material, alone or in conjunction with any other material of any kind
or nature except that SMART and its agents, employees, licensees, and/or assignees shall not use the Information for any criminal or illegal purpose, or in a
manner inconsistent with community standards of decency.
I understand and agree that the Department of Defense is and shall be the exclusive owner of all right, title, and interest, including copyright, in the Works, and
any commercial, informational, educational, advertising, or promotional materials containing the Information. I am of full legal age, I have read the Release, and I
am fully familiar with its contents.
Name:

Signature:

Date (YYYYMMDD):

Legal Guardian Signature required if SMART Scholarship Program participant is under 18 years of age at time of award.

DD FORM 3067-5, 20220701 DRAFT

PREVIOUS EDITION IS OBSOLETE.

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