REGISTRATION FOR SCIENTIFIC AND TECHNICAL INFORMATION SERVICES
(Read Privacy Act Statement and Instructions on back before completing this form.)
OMB No. 0704-0264
OMB approval expires
Nov 30, 2010
SECTION I - GENERAL INFORMATION (All applicants must complete Section I.)
FOR DTIC USE ONLY
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. SEND YOUR COMPLETED FORM TO: DEFENSE TECHNICAL
INFORMATION CENTER, ATTN: DTIC-BC, 8725 JOHN J. KINGMAN ROAD, SUITE 0944, FORT BELVOIR, VA 22060-6218.
The public reporting burden for this collection of information is estimated to average 25 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, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0704-0264). Respondents should be aware that notwithstanding any other provision 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.
1. ORGANIZATION NAME
2. SUBORGANIZATION NAME
3.a. CLASSIFIED/BUSINESS MAILING ADDRESS
b. CITY c. STATE d. ZIP CODE
4. ATTENTION
a. NAME (Last, First, Middle Initial) c. POSITION/TITLE d. OFFICE SYMBOL
5. TELEPHONE NUMBER (Include area code)
a. COMMERCIAL b. DSN
6. FAX NUMBER (Include area code)
7. E-MAIL ADDRESS
8.a. PRIME CONTRACT NUMBER
(Contractors only)
b. EXPIRATION DATE
(YYYYMMDD)
a. COMMERCIAL b. DSN
b. SSN
DTIC USER CODE
USER TYPE
CHARGE CODE
SERVICE LEVEL SPONSOR
FACILITY CLEARANCE
ENTITY CODE
SECURITY CLEARANCE
11. CAGE CODE
TYPE RD CNWDI NATO
12. DUNS NUMBER
9. CURRENT OR FORMER DTIC
USER (X one)
NO
YES (Enter DTIC user code)
10.a. MILITARILY CRITICAL TECHNICAL DATA AGREEMENT
CERTIFICATION NUMBER (Contractors only)
b. EXPIRATION DATE
(YYYYMMDD)
13. TYPE OF ACCESS REQUESTED (X as applicable)
UNCLASSIFIED/LIMITED (Controlled distribution)
UNCLASSIFIED/UNLIMITED (Public release)
a. UNCLASSIFIED: c. SPECIAL ACCESSES:
RESTRICTED DATA
CNWDI
NATO UNCLASSIFIED
NATO CONFIDENTIAL
NATO SECRET
CNWDI DATE BRIEFED:
NATO DATE BRIEFED:
SECTION II - SECURITY OFFICER (Complete Section II if requesting access to classified data.)
14. SECURITY OFFICER CERTIFICATION
I certify that the organization listed in Section I may receive and store classified data at the access level indicated in Section I, and the
individual listed in Section I has been cleared and briefed for all requested special accesses.
a. NAME (Last, First, Middle Initial) b. ORGANIZATION NAME
e. TELEPHONE NUMBER (Include area code)
(1) COMMERCIAL (2) DSN
f. SIGNATURE g. DATE SIGNED (YYYYMMDD)
c. E-MAIL ADDRESS d. SSN
SECTION III - U.S. GOVERNMENT APPROVING OFFICIAL (DOD organizations requesting access to classified data, Non-DOD Government
organizations requesting access to unclassified, limited or classified data, and all contractors requesting either unclassified or classified data must
complete Section III. See Instructions for detailed explanation of Government Approving Official.)
15. APPROVING ORGANIZATION NAME 16.a. BUSINESS ADDRESS b. CITY c. STATE d. ZIP CODE
17.a. APPROVING OFFICIAL NAME (Last, First, Middle Initial) b. POSITION/TITLE
e. TELEPHONE NUMBER (Include area code)
f. SIGNATURE g. DATE SIGNED (YYYYMMDD)
(1) COMMERCIAL (2) DSN
FOR DTIC USE ONLY
c. E-MAIL ADDRESS d. SSN
DD FORM 1540, NOV 2007
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional 7.0
FOR OFFICIAL USE ONLY
CONFIDENTIAL
SECRET
b. CLASSIFIED:
