Self-Certification for Access to Certain Department of Energy
Unclassified Nuclear Information, Official Use Only Information and
Export Controlled Information .

I
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
certify as follows:

1\. I am a United States citizen: by birth (date, State and City of
birth \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_) or by naturalization (date
and place of naturalization
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_).

2\. I represent the
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Company. My business address and phone numbers are:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

3\. The \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Company is a US owned company with Corporate Headquarters located at
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

4.a. The \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Company has no foreign national employees.

## Or

4.b. The
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Company
has foreign national employees in the following positions: (Attach
additional sheets if necessary)

I acknowledge that I will be contacted for further information regarding
these foreign national employees, their roles within the company and the
extent to which they may need access to the protected information for
purposes of responding to the Request For Information and the
anticipated Request For Proposals.

5\. I understand and acknowledge my responsibilities regarding \"need to
know\", access, control, reproduction and destruction, as specified in
Attachment 1 to this Self-Certification, of Department of Energy
Unclassified Nuclear Information, Official Use Only Information and
Export Controlled Information provided to me. This information is being
provided solely for the specific purpose of responding to a Request For
Information and an anticipated Request For Proposals. I further certify
that all company employees having access to the information are entitled
to such access, and that they understand and will comply with the
requirements of Attachment 1.

6\. I will limit and control the reproduction and dissemination of the
DOE information to the minimum required for responding to the Request
For Information and the anticipated Request For Proposals. I will ensure
that ALL the information received pursuant to this Self-Certification is
destroyed in accordance with Attachment 1 at the conclusion of the
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Company\'s participation in
this procurement process. I acknowledge that I will be required to
certify that destruction of all sensitive information received through
this procurement process has been completed in compliance with
Attachment 1.

7\. I acknowledge that I may be contacted to verify the statements made
in this Self-Certification and that the
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Company may
be visited to ensure proper information security practices are in place
and being followed.

### CERTIFICATION THAT MY ANSWERS ARE TRUE

My statements in this Self-Certification form, and any attachments to
it, are true, complete and correct to the best of my knowledge and
belief. They are made in good faith for the purpose of obtaining access
to certain Department of Energy Unclassified Nuclear Information,
Official Use Only Information and Export Controlled Information. I
understand that a knowing and willful false statement in this
Self-Certification can be punished by fine or imprisonment or both,
pursuant to 18 United States Code, Section 1001.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name and Title Date