Instructions for Completing PR001100 Form
Use the Sample Form Below with the letters on it corresponding to each step in the Instructions Below:
1Supplier shall include on the Agile form (PR001100)
Current Date
Section 1.1- Last Name, First Name and Middle Initial
Section 1.2- Work Phone Number
Section 1.3- Company Name and Applicant’s Site Address
Section 1.4- Applicant’s Business/ Company e-mail address
Section 1.5- Applicant’s Title
Section 1.6- COMSEC and FOUO information:
If supplier has COMSEC account and was briefed on COMSEC by supplier’s COMSEC custodian - select “YES” for COMSEC
Suppliers that do not have COMSEC account -select “NO” for COMSEC
If supplier has only Standard NDA with ViaSat – select “NO” for FOUO
If supplier has FOUO NDA with ViaSat and was briefed on FOUO by supplier’s Security Officer or HR- select “YES “ for FOUO
Section 1.7- Account name and account action
Section 1.8- Access Justification
Section 1.9-ViaSat Point of Contact
Section 2.1- Applicant’s Country of Citizenship
Section 2.2- Applicant’s Country of Residence
Section 2.3-Dual Citizenship information ( if applicable)
Section 2-A- U.S. Citizens information:
If applicant is U.S. citizen- one of the options must be selected in this section
Section 2-B- Non U.S. Citizens ( U.S. Persons) information:
If applicant is not a U.S. citizens, but a legal U.S. resident – one of the options must be selected in this section
Section 3- Non U.S. Person information - if applicant is Non U.S. citizen or resident the following information must be provided:
Section 3.1-country of Citizenship
Section 3.2- Country of Birth
Section 3.3-Dual citizenship information ( if applicable)
Section 3.4- Unexpired foreign passport #
or
Section 3.5- Other Non-U.S. document information establishing country of citizenship
Section 3.6- Document Type Specification
Section 4- Applicant’s Signature and current Date
Section 5- Supplier’s Point of Contact Information:
Country where supplier’s company was founded
Supplier’s Agile POC’s name
Supplier’s Agile POC’s e-mail address
Supplier’s Agile POC’s signature
Current date
Section 6- To be completed by applicant’s company Security Officer or HR (Human Resources) Representative.
Supplier’s COMSEC account # ( if applicable)
COMSEC information- supplier’s Security Officer or HR has to validate the COMSEC information by selecting option “YES” or “NO” in section 6.
FOUO information- supplier’s Security Officer or HR has to validate FOUO information by selecting option “YES” or “NO” in section 6.
COMSEC and FOUO information in section 1.5 and 6 has to match.
Security Officer’s Signature- supplier’s Security Officer has to validate the information by signing the application in section 6.
If supplier’s company does not have Security Officer, then HR representative has to validate the information indicated on the Agile application and sign the form in section 6.
Request Form: ViaSat Agile Access
A-Date: _______________
EXPORT CONTROL STATUS VERIFICATION
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The purpose of this form is to assist in verifying your export control status. U.S. laws and regulations prohibit the unauthorized export of restricted technology to certain persons. To comply with these legal requirements, ViaSat must ascertain whether an individual who may be given access to restricted technology is a “foreign person” subject to these export control restrictions. Regardless of individual status, persons directly employed by an entity not organized or incorporated in the U.S. will be treated as foreign persons for purposes of access to restricted technology. Certain categories of persons, referred to as U.S. persons” who are employed by U.S. entities, are not considered foreign persons and do not need export licenses before being allowed access to restricted technology. The list of documents contained in section 2b should be used to verify someone is a U.S. person. If an individual whose export control status is being verified furnishes a document from the list in section 2a and indicates their employer is incorporated or organized in the U.S. in section 1, the individuals is a U.S. person for export control purposes, and does not need an export license before being given access to restricted technology. All others are provided access to restricted technology only with appropriate U.S. government authorization. INSTRUCTIONS 1. Review and complete either section 2 or 3 (as appropriate), sign, and date. You are required to furnish unexpired, original documents, except where noted. 2. If you are an external partner or employee of ViaSat affiliate not incorporated in the U.S., you are also required to complete section 3. 3. A company Security representative or Human Resources, or designee, inspects the documents, verifies the accuracy of the information provided below, and certifies.
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Section 1 - To be Completed by Applicant
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1. Last Name, First Name and Middle Initial-B
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2. Work Phone - C
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3. Company Name and Applicant’s Site Address (Please Include Internal Company Mail Routing Point if Applicable)
D
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4. Applicant’s Business/Company Email Address:
E
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5. Applicant’s Title:
F
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6. I have been COMSEC briefed YES G -a NO G -b (If YES is checked, you must indicate the COMSEC Account # in Section 6)
I have been FOUO briefed YES G -d NO G -c (if YES is checked, FOUO NDA must be on file with ViaSat)
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7. Account Action Requested (Check One Box) New
Revise Suspend Cancel Reinstate (Account Name)____ H ____________________________
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8. Justification for Access I
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9. ViaSat Point of Contact: J
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Section 2 - Citizenship Verification CHECK IF THIS SECTION APPLIES TO YOU
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Country of Citizenship
K
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2.Country of Residence
L
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3. Dual Citizenship? Yes No If Yes, List all other countries:
M
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A. U.S. CITIZENS N -a
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B. NON U.S. CITIZENS (U.S. Persons) O-a
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Unexpired United States passport or passport card
Certificate of United States citizenship (USCIS form N-560 or N-561)
Certificate of naturalization (USCIS Form N-550 or N-570)
Certificate of birth abroad issued by the U.S. Department of State (Form FS-545 or DS-1350) or Report of Birth Abroad (FS-240)
Original or certified copy of a birth certificate issued by a state, county, municipal authority, or outlying possession of the United States, bearing an official seal
U.S. citizenship status confirmed in JPAS. Note: This option may ONLY be used by U.S. government security or human resources representatives in verifying the citizenship of U.S. government employees, and is not for use by or for contractor personnel.
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Unexpired temporary resident card (USCIS Form 1-688, not 1-688A or 1-688B)
Unexpired re-entry permit (USCIS Form I327)
Unexpired refugee travel document (USCIS Form I-571)
Alien registration receipt card with photograph (USCIS Form I-551 or I-151
Unexpired foreign passport with I-551 stamp
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Section 3 - For Non-U.S. Persons CHECK IF THIS SECTION APPLIES TO YOU --
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1. Country of Citizenship P-a
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2. Country of Birth P-b
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3. Dual Citizenship? Yes No If Yes, List all other countries: P-c
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4. Unexpired foreign passport (with I-94 if available) P-d
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Expiration Date
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5. Other Non-U.S. document establishing country of citizenship* P-e
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Expiration Date
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6. Specify Type of Document P-f
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Section 4 - Computer System User Acknowledgement Statement
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I understand that ViaSat considers access, data, programs, software and/or any other information stored in its automated information systems or under its jurisdiction to be proprietary, even though such information may not be marked as such. I agree not to copy, use or disclose to others any such information without prior authorization of the owner of the information. Additionally, I understand that all activities associated with ViaSat automated information systems, which includes my accesses and account(s), are subject to electronic monitoring. Furthermore, I agree that I will: · Memorize my passwords and not display them where they may be compromised. · Not permit another individual to use my User ID and password to obtain access. · Not use passwords that can be identified or directly attributed to me (such as common family names, social security account numbers, telephone number or project names). Immediately notify the appropriate ViaSat management or point of contact when I no longer require access to the automated information systems(s). · Immediately report any violation of automated information system resource controls to the appropriate management or point of contact. · Periodically clear the browser cache and the contents of any temporary directories to which data may have been copied while accessing a ViaSat automated information system. · I validate that my computing device is configured to launch a password-protected screensaver after no more than 10 minutes of inactivity. I understand that failure to abide by the above may result in disciplinary action, termination of my access to ViaSat automated information system(s), prosecution under 18 USC 1905 and other action as deemed appropriate by ViaSat. By my physical or electronic signature below, I acknowledge that, as a user of a ViaSat computer system, it is my responsibility to comply with all measures necessary to prevent unauthorized disclosure, modification or destruction of information. I acknowledge and accept the computer usage statements above.
Applicant Signature:________Q____________________________________ Date:___________ Q ___________
Section 5a - Computer System User Acknowledgement Statement
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Section 5 – Point of Contact Ownership & Acknowledgement: ti-on 5a - Computer System User Acknowledgement Statement
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The Supplier Point of Contact listed below (POC); will be responsible for requesting named accounts for all employees at your facility and for ensuring your employees do not share their credentials with others. The POC is also responsible for facilitating requests for additional accounts, when required, and must promptly notify ViaSat when your employees no longer require access to the Agile system. The POC will also assist with ViaSat’s audit of your facility’s Agile access by confirming the list of employees on a periodic basis.
As the company’s Point of Contact with ViaSat, I concur that the above listed employee requires network access as needed for the purposes of quotations or to fulfill contractual obligations of existing purchase orders.
Is your company incorporated or organized in the U.S.? R-a Yes No If “No”, please identify country:_____________________________
POC Name (print)_____R-b_________________________________ POC E-Mail Address: ______R-c____________________________
Signature:___________________R-d____________________________Date:_____R-e_____
(Note: Maximum of 15 users per supplier site, if more are required, please contact your ViaSat Supply Chain POC)
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Company has an active COMSEC account – COMSEC Account # ____S-a__________________
S-b COMSEC Briefing YES NO (If YES is checked, you must indicate the COMSEC Account # above)
I verify that the applicant handling Comsec material meets the eligibility requirements and has received a Comsec or Cryptographic
briefing prior to access. This briefing is in accordance with the National Security Agency NSA/CSS Policy Manual 3-16
S-c FOUO Briefing YES NO
I verify that the applicant handling FOUO material has been briefed on ViaSat’s FOUO Requirements per the FOUO NDA
5 - Computer System User Acknowledgement Statement
Security Validation (Applicant’s Security Officer) Applicant’s Security Office - if other than a company Security Officer,
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( )
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Applicant’s Security Office - if other than a company Security Officer,
please indicate organizational title
S-e
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Print Name
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Phone
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S-d
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Signature:
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By signing this form I have validated that all the information is true and accurate.
PR001100 Rev 009 Page of ViaSat Proprietary Data
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