Registration Form for use of the CCR Tools
U.S. Government Sponsored Contractors
Please TYPE or PRINT CLEARLY then mail or fax this form to us:
Mail: FAX:
DLIS-SXB (CCR Tools Access) DSN 661-7243
Defense Logistics Information Service Commercial ( 269) 961-7243
74 Washington Ave N Ste 7
Battle Creek MI 49017-3084
Instructions for completing this form
This is a Department of Defense (DoD) computer system. DOD computer systems are provided for the processing of official U.S. Government information only. All data contained on DoD computer systems is owned by the Department of Defense, may be monitored, intercepted, recorded, read, copied, or captured in any manner and disclosed in any manner, by authorized personnel. There is no right to privacy in this system. System personnel may give to law enforcement officials any potential evidence of crime found on DoD computer systems. Use of this system by any user, authorized or unauthorized, constitutes consent to this monitoring, interception, recording, reading, copying, or capturing and disclosure.
Block 1. Sponsor Information – This block must be completed and signed by the U.S. Government Contracting Officer Representative.
U.S. Government Sponsor Branch of Service: ______________________________
(Example: Navy, Air Force, NASA, Dept of Treasury).
Major Command: _____________________________________________________
(Example: Naval Supply Command, Bureau of Public Debt, etc.)
Government Contract Officer Representative (COR) By signing this block, you agree that the contractor named in Block 3 needs access to CCR Tools in order to perform their contractual obligations at your agency.
COR Signature:___________________________________________________
COR Name (print):________________________________________________
Office Symbol/Code/Mail Stop:______________________________________
Organization:___________________________________________________
Street/PO Box:__________________________________________________
City/State/ZIP Code:_____________________________________________
City/Country (If APO or FPO address):_______________________________
Commercial Phone:_____________________DSN:____________________
Email Address:____________________________________________
FAX:______________________________
LEVEL OF ACCESS;
______ Proprietary Information
______ Sensitive Information (personal & financial data)
Block 2. Contractor Information
POC Name:__________________________________________________
Company Name:______________________________________________
Street Address/PO Box:_________________________________________
City/State/ZIP Code:____________________________________________
City/Country:__________________________________________________
Commercial Phone:______________________DSN:__________________
FAX:_______________________Email:____________________________
Contract Number:______________________________________________
Contract End Date:___________________________________________
Block 3. Security Verification
If you are a DoD sponsored contractor you must have this block completed by your Contract Officer Representative/Security office. If received without annotation and signature, your form will be returned without further action.
Verification of Security for requester named in Block 2:
Employee Name:_____________________________________________
Type of Investigation: _____________ Completed on:_________________
ADP Level ______________________
By (Agency):_________________________________________________
Signature of Security Representative: :______________________________
Printed Name of Security Reprensentative:__________________________
Title___________________________________ Date________________
Commercial Phone ________________________ DSN _________________
Block 4. CCR Tools User Information
This form requests that you provide your social security number. The U.S. Government is authorized to ask for this information under Executive Orders 9397, 10450 and 0577 sections 3301 and 3302 of title 5, U.S. Code and parts 4, 731 and 736 of Title 5, Code of Federal Regulations. Your social security number is needed to keep records accurate, because other people may have the same name. The primary use of the information on this form is for review by Government Officials to determine and verify that you have the appropriate security clearance to obtain access to the requested data. Disclosure is voluntary. However, failure to provide the requested information may result in denial of access.
As a user of CCR Tools, I acknowledge my responsibility to conform to the following requirements and conditions as established by Defense Logistics Agency:
I understand the need to protect my password. I will NOT share my password and/or account.
I understand that I am responsible for all actions taken under my account. I will NOT attempt to ‘hack" the network or any connected information system or network, or attempt to gain access to data for which I am not specifically authorized.
I acknowledge my responsibility to comply with all copyright laws both federal and state (where applicable).
I understand my use of Defense Logistics Agency Information systems is subject to monitoring to ensure proper functioning, to protect against improper or unauthorized use or access, and to verify the presence or performance of applicable security features or procedures. By using the information system I consent to such monitoring.
I acknowledge my responsibility to conform to the requirements stated above when using Defense Logistics Agency information systems or networks. I also acknowledge that failure to comply with these requirements and conditions may constitute a security violation resulting in denial of access to Defense Logistics Agency information systems, networks or facilities and that such violations will be reported to appropriate authorities for further action as deemed appropriate.
I understand the need to protect my password. I will NOT share my password and/or user ID. If I no longer need access to CCR Tools, it is my responsibility to notify DLIS.
USER SIGNATURE______________________________________________
Printed Name:___________________________________________________
Social Security Number (last six digits):______________________________
DLA Standard LOGON or User ID:__________________________________
Email:__________________________________________________________
Commercial Phone:________________________DSN:__________________
Personal Identification Information (This may be your favorite color, sports team, hobby or phrase.) ________________________________________________________
Block 5. Non-Disclosure Statement
NON-DISCLOSURE AGREEMENT
FOR CCR INFORMATION
1. To carry out the duties as the information dissemination (ID) source for the Central Contractor Registry (CCR), the Defense Logistic Information Service (DLIS) may disclose information to authorized representatives of the United States (U.S.) Government. This Non-Disclosure Agreement ("Agreement") covers information provided to the Department of Defense (DoD) under a mandate for federal contractors as described in 48 CFR, Parts 204, 212, and 252 and the Debt Collection Improvement Act of 1996, Public Law 104-134. The disclosure, of such information, to the public or outside of the Government shall be in accordance with all conditions and limitations set forth herein.
2. The Data Receiver has a requirement(s) for such data to perform certain tasks on behalf of the U. S. Federal Government. Because of this requirement(s), The Data Receiver is considered "authorized" for the purpose of this Agreement.
3. DLIS hereby determines that disclosure of information described in paragraph 1 from the Central Contractor Registration (CCR) system (data described in the Handbook) is necessary so that The Data Receiver may perform the duties required of them by the U. S. Federal Government.
4. DLIS shall grant access to information described in paragraph 1 until such time as the information is no longer required for the performance of work on behalf of the U. S. Federal Government or The Data Receiver request termination of access or DLIS terminates access.
5. The Data Receiver accepts the obligations contained in this Agreement in consideration of being granted access to the information described in paragraph 1.The Data Receiver acknowledges that all obligations imposed by this agreement concerning the use and disclosure of such information apply for the duration of the requirement and at all times thereafter.
6. The Data Receiver agrees that it shall use the information described in paragraph 1 only for the purpose of the work required by the U. S. Federal Government and shall not use such data for commercial purposes.
7. The Data Receiver agrees it shall not disclose or provide access to information described in paragraphs 1 to anyone unless it has verified that the recipient has been properly authorized to receive such information, e.g., employees of The Data Receiver or contractors who have signed Employee/Subcontractor Non-Disclosure Agreements pursuant to this Agreement.
8. The Data Receiver agrees to adopt operating procedures and physical security measures to properly safeguard such information from unauthorized use and from disclosure or release to unauthorized third parties.
9.The Data Receiver agrees to return to DLIS all copies of any abstracts or extracts of data described in paragraphs 1, of which it has possession pursuant to this Agreement, upon request of DLIS or the completion or termination of the tasks set forth by the U.S. Federal Government, whichever comes first.
10.The Data Receiver agrees to obtain a written agreement to honor the terms of the Agreement from each contractor, sub-contractor and employee of the contractor or subcontractor who will have access to such information before the contractor, sub-contractor or employee is allowed such access.
11.The Data Receiver hereby acknowledges that no contractor, sub-contractor, consultant or employee who will have access to such information is debarred, suspended or otherwise ineligible to perform on an U. S. Federal Government contract.
12.The Data Receiver hereby acknowledges that any violation or breach of this Agreement on the part of a contractor, sub-contractor, consultant or any employee of a contractor or sub-contractor shall constitute grounds for termination of access to such information; suit for damages; suit to enforce the Agreement, including but not limited to, application for a court order prohibiting disclosure or use of information in violation or breach of this Agreement; and or suit for civil fines or penalties. The Data Receiver further acknowledges that the unauthorized use, disclosure or retention of the information may constitute a violation of the U.S. criminal laws, including provisions of sections 641, 793, 794, and 1905, title 18 U. S. Code, and that nothing in this Agreement constitutes a waiver by the U. S. of the right to prosecute for any statutory violation.
____________________________
Signature of data receiver
__________________________
Title
__________________________
Date