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Certification and Representation Form

Certification and Representation Form

Certification and Representation Form

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GENERAL DYNAMICSCERTIFICATION AND REPRESENTATION REGARDING FOREIGNOWNERSHIP, CONTROL OR INFLUENCE (FOCI)THIS FORM MUST BE COMPLETED AND SIGNED BY AN OFFICER, OWNER OR EMPOWERED OFFICIAL OF OFFEROR.IF ANY OF THE INFORMATION IN THIS DOCUMENT CHANGES, OFFEROR MUST PROMPTLY NOTIFY EB.Section 1 – Business Information1. Legal Entity Name:_______________________________________________________DBA or Division (if applicable):_______________________________________________________2. Principal Address (Number, Street):_______________________________________________________City (Town), State & Postal Code (Full 9 Digits for US Zip Codes):_______________________________________________________Country:__________________________POC Email:__________________________3. Manufacturing / Performance Address (Number, Street) (for workproposed to be performed hereunder):_______________________________________________________City (Town), State & Postal Code (Full 9 Digits for US Zip Codes):_______________________________________________________Country:__________________________Telephone:__________________________POC Email:__________________________Facsimile:__________________________Telephone:__________________________Facsimile:__________________________Offeror’s business status (Check one):Individual / Sole Proprietor Corporation Partnership Trust/EstateGovernment Agency Non-Profit Organization Private Foundation Non-US EntityThe Offeror’s Commercial And Government Entity (CAGE) is as follows:CAGE Code: _______________No CAGE CodeSection 2 – <strong>Certification</strong>s <strong>and</strong> <strong>Representation</strong>s regarding Foreign Ownership Control ORInfluence (FOCI)Instructions:US Companies – Complete Parts (1) – (8) <strong>and</strong>, for access to Naval Nuclear Propulsion Information (NNPI), Part (10)Canadian Companies – Complete Parts (1) – (5) <strong>and</strong> (11)UK <strong>and</strong> Australian Companies – Complete Parts (1) – (4) <strong>and</strong> (9)Other Non-US Companies – Complete Parts (1) – (4)(1) Offeror is organized <strong>and</strong> existing under the laws of _________________________ (State / Province) in ________________________ (Country).(2) Ownership <strong>and</strong> / or Affiliate Status:Offeror represents <strong>and</strong> certifies that it:Is Is not owned or controlled, in whole or in party, by another company or entity.Is Is not a division or subsidiary of another company or entity.Is Is not owned or controlled, in whole or in part, by the government of a country. If it is, name of country: ________________________If Offeror is owned or controlled by another company or entity or is a division or subsidiary of another company or entity, Offeror must provide thefollowing information (attached additional pages if needed):Name of Immediate Parent:Address of Immediate Parent:Place of Incorporation:EB <strong>Form</strong> No. 84-03-2205 Rev 11/2012(Replaces Prior Rev. 4/2012) 75 Eastern Point Road, Dept. 330, Groton, CT 06340PAGE 1 of 4


Offeror’s relationship to Immediate Parent:Name of Ultimate Parent:Address of Ultimate Parent:Place of Incorporation:Offeror’s relationship to Ultimate Parent:(3) Information Regarding Offeror’s Employees:Does Offeror employ dual nationals <strong>and</strong> / or third country nationals?Yes NoIf yes to the preceding question, do these employees require access to any technical data or hardware?Yes NoIf yes to the preceding question, in the space below provide the nationality or dual nationality of each such employee._______________________________________________________________________________________________________________________.If no, does Offeror have an Access Control Plan/Technology Control Plan preventing intentional or unintentional access to controlled EB technicaldata <strong>and</strong> products?Yes No(4) Control of Access to U.S. Technical Data Other Than Naval Nuclear Propulsion Information (NNPI):The Offeror:Has Does not have a written Access Control Plan/Technology Control Plan (ACP/TCP) to prevent the unauthorized export ordisclosure of Technical Data, regardless of whether such export or disclosure occurs within the U.S. or abroad. Release to unauthorized personsincludes unauthorized employees, unauthorized foreign nationals <strong>and</strong>/or foreign interests, as well as release to the public.(5) (U.S. <strong>and</strong> Canadian offerors only). U.S./Canada Joint <strong>Certification</strong> Program (JCP) certification through the Defense Logistics Information Service(DLIS):JCP <strong>Certification</strong> establishes the eligibility of a U.S. or Canadian contractor to receive certain technical data subject to U.S. <strong>and</strong>/or Canadian exportcontrol laws <strong>and</strong> regulations. For DLIS FAQ <strong>and</strong> application form, visit http://www.dlis.dla.mil/jcp/.The Offeror (check one only):a) Has an active JCP certification. <strong>Certification</strong> number: _______________. Expiration Date: _______________.b) Does not have an active JCP certification.c) Has applied for a JCP certification through DLIS <strong>and</strong> will notify EB promptly of its certification number <strong>and</strong> expiration date whenOfferor’s certification is in place.(6) (U.S. offerors only). Department of Defense (DoD) Directives on Control of Technical Data (Note: DoD Directives can be accessed athttp://www.dtic.mil/whs/directives/corres/dir.html):The Offeror:Has Has not read DoD Directive 5230.24, “Distribution Statements on Technical Documents”, <strong>and</strong> DoD Directive 5230.25,“Withholding of Unclassified Technical Data From Public Disclosure,” <strong>and</strong> if it has;Agrees Does not agree to comply with the applicable requirements of DoD Directives 5230.24 <strong>and</strong> 5330.25.(7) (U.S. offerors only). U.S. State Department Registration:The Offeror:Is Is not registered as a manufacturer or exporter of defense articles or provider of defense services pursuant to the InternationalTraffic in Arms Regulations (ITAR), 22 CFR 122.Is Is not registered as a broker per ITAR Part 129.If applicable, Offeror represents that its registration per this section 7 is in effect until ____________________.(8) (U.S. offerors only). Foreign Ownership, Control or Influence (FOCI):For the purposes of this section, “Foreign National” <strong>and</strong> “Foreign Interest” shall have the same meaning as defined in OPNAVINST N9210.3.“Significant Interest” shall have the meaning given it in the clause at DFARS 252.209-7001.EB <strong>Form</strong> No. 84-03-2205 Rev 11/2012(Replaces Prior Rev. 4/2012) 75 Eastern Point Road, Dept. 330, Groton, CT 06340PAGE 2 of 4


An Offeror is considered to be subject to FOCI if – It is owned or controlled by a “Foreign National” or “Foreign Interest”; or A “Foreign National” or “Foreign Interest” has a “Significant Interest” in Offeror’s company or any parent of Offeror; or It is in partnership with a “Foreign National” or “Foreign Interest”.(a) For each company or entity identified in this form, Offeror represents to EB that a foreign person(s), foreign entity, or foreign government,individually or collectively, holds (Check all that apply):Ownership of or a beneficial interest in at least 5 percent of such entity’s securities. Beneficial interest includes holding 5% or more ofAny class of the company’s securities in “nominee shares,” “street names,” or some other method of holding securities that does not discloseThe beneficial owner;A management position in the firm, such as a director or officer;The ability to control or influence the election, appointment, or tenure of directors or officers in the company;Ownership of 10 percent or more of the assets of a firm such as equipment, buildings, real estate, or other tangible assets;50% or more of the indebtedness of a firm.If Offeror checked any of the boxes in 8(a), provide specific details including nationality of such owners, controllers, or interests: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(b) Does any foreign person(s), foreign entity, or any government, have the power, direct or indirect, whether or not exercised, <strong>and</strong> whether or notexercisable through ownership of the company’s securities, by contractual arrangements or other means, to direct or decide matters affecting themanagement or operations of any of the companies or entities identified in this form, in a manner that might result in unauthorized access toU.S. technical data or information or adversely affect the performance of classified <strong>and</strong>/or unclassified contracts?Yes NoIf yes to the preceding question, provide specific details: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(c) If the certifying company is subject to FOCI <strong>and</strong> is a US entity, is there a Proxy Agreement, Special Security Agreement <strong>and</strong>/or a GovernmentSecurity Committee in place at the request of Defense Security Service (DSS) (Seehttps://www.dss.mil/GW/ShowBinary/DSS/isp/foci/foci_faqs.html)?Yes NoIf yes to the preceding question, provide specific details: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(9) (U.K. & Australian offerors only). Verification of United Kingdom <strong>and</strong> Australian Companies’ Eligibility to Participate in US-UK Defense TradeCooperation Treaty (effective 4/20/2012) or US-Australia Defense Trade Cooperation Treaty (effective date to be announced):The U.S. State Department’s Treaty Reference System (TRS) assists U.S. exporters in confirming whether a UK or Australian company is a memberof the UK or Australian Approved Communities (AC), <strong>and</strong> is therefore an eligible recipient of items exported pursuant to the exemptions created bythe Treaties. AC members are assigned an Approved Community Identification Number (ACID) once approved for membership in the community.With the ACID, U.S. exporters can confirm AC membership prior to export by entering the ACID into TRS at https://trs.pmddtc.state.gov.Offeror’s Approved Community Identification Number (ACID): ____________________________________.(10) (U.S. Offerors that require access to NNPI only). Control of Access to Naval Nuclear Propulsion Information (NNPI):The Offeror (complete each line below):(a) Has Has not read OPNAVINST N9210.3 (excluding Table 2) <strong>and</strong>, if EB approves the Offeror for access to technical dataincluding NNPI, it;(1) Agrees Does not agree to comply with the applicable requirements of that publication including the more stringentRequirements for controlling access to <strong>and</strong> disclosure of NNPI.(2) Has Does not have a written Access Control Plan/Technology Control Plan (ACP/TCP) that complies withOPNAVINST N9210.3 <strong>and</strong> (A) appropriately safeguards NNPI from unauthorized actual, potential, or inadvertent release in anyform, classified or unclassified, <strong>and</strong> (B) restricts access to NNPI to U.S. citizens who are not “Representatives of a Foreign Interest”<strong>and</strong> who have a “need-to-know,” as such quoted terms are defined in OPNAVINST N9210.3.(11) (Canadian Offerors only):Definitions:“Canadian-Registered Person” means “any Canadian national (including Canadian business entities organized under the laws of Canada), dualcitizen of Canada <strong>and</strong> a third country (subject to §126.1), <strong>and</strong> permanent resident registered in Canada in accordance with the Canadian DefenceEB <strong>Form</strong> No. 84-03-2205 Rev 11/2012(Replaces Prior Rev. 4/2012) 75 Eastern Point Road, Dept. 330, Groton, CT 06340PAGE 3 of 4


Production Act, <strong>and</strong> such other Canadian Crown Corporations” as may be identified by the U.S. International Traffic in Arms Regulations (22 CFR120-130).(a) Name <strong>and</strong> address of all Offeror entities / locations which require access to technical data or defense services: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(b) The Offeror is (Check one):A Canadian Federal or Provincial governmental authority acting in an official capacity; or,A “Canadian-registered person” in accordance with the Canadian Defence Production Act; in which case, Offeror’s registration number is_______________ OR Offeror’s application for registration in Canada was / will be made on ________________.(c) Non-Canadian-registered persons (other than U.S. citizens working on this project / program), whether within Offeror’s company or otherwise,Will Will not require access to technical data or commodities.(d) If subcontractors will be required to perform work, such subcontractors:Will Will not require access to U.S. technical data.If subcontractors will require access to U.S. technical data, identify such subcontractors by company name <strong>and</strong> address here: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Section 3: AUTHORIZED SIGNATURE OF OFFEROR<strong>Certification</strong> by an Official of Offeror or Offeror’s Authorized Representative:By submitting this information, I am attesting to the accuracy of the information contained herein. I underst<strong>and</strong> that I may be subject to penaltiesimposed by the United States Government if I misrepresent any of the representations or certifications herein. I further acknowledge on behalf ofOfferor that EB shall rely on the information provided by Offeror herein <strong>and</strong> that if any of Offeror’s representations herein change during the periodof performance, Offeror shall provide immediate written notice to the EB’s representative to whom this document was originally provided. Bysigning below, I certify that I am an Officer, Owner or Empowered Official of Offeror duly authorized to sign this document on behalf of Offeror <strong>and</strong>that to the best of my knowledge, the information provided in this document is current, accurate, <strong>and</strong> complete as of the date set forth below.__________________________________________________________Signature of Offeror or Offeror’s Authorized Representative__________________________________________________________Printed Name <strong>and</strong> Title of Signatory__________________________________________________________Offeror’s Company Name__________________________________________________________Company Address_____________________________ __________________________ __________________________Date Telephone: Facsimile:EB <strong>Form</strong> No. 84-03-2205 Rev 11/2012(Replaces Prior Rev. 4/2012) 75 Eastern Point Road, Dept. 330, Groton, CT 06340PAGE 4 of 4

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