Non-Disclosure for Access to Certain Department of Energy Unclassified Controlled

NON-DISCLOSURE AGREEMENT FORM FORACCESS TODEPARTMENT OF ENERGY

HANFORD MISSION ESSENTIAL SERVICES CONTRACT (HMESC) SOLICITATION NO.89303318REM000007

CONTROLLEDUNCLASSIFIED INFORMATION

I, , herebycertifythat:

1. I am a United States citizen bybirth(date, Stateand Cityof birth

)

2. Isign this form in mycapacityas

[TITLE]of

[NAME OFCORPORATION,LLC,

PARTNERSHIP, COLLEGE/UNIVERSITY, NOT-FOR-PROFIT, ETC.](the

“Company”). Mybusiness address and telephonenumbers are:

3. TheCompanyisnot foreign owned; it is U.S. owned, whose corporate headquarters orprincipalplaceof business is

.

4. Iunderstand and agreethat theterm “Company” and the certifications contained

herein refer onlyto the entityidentified in paragraph 2.

5. Iunderstand and agreethat if theCompanyis partofa consortium, joint venture, orotherteamingarrangement, orif theCompanyhas a parent or subsidiary corporation, each parentorsubsidiarycorporation, or eachentitycomprisingthe consortium, joint ventureor other teamingarrangement must submita“Non- DisclosureAgreement FormforAccess to Department ofEnergy Hanford Mission Essential Services Contract (HMESC) Solicitation No. 89303318REM000007 Controlled Unclassified Information”agreement form in order to gainaccess to CONTROLLED UNCLASSIFIEDINFORMATION. Under nocircumstances shall theCompanysharethis CONTROLLED UNCLASSIFIED INFORMATION with anotherentity, including aparent orSubsidiary Corporation, or anemployee thereof.

6. I am an officer of theCompany. There exists a relationship between meand the Company, which,forpurposes ofthis form, means that the certifications contained herein arelegallybindingon both me and the Company.

7. Forpurposes of this form,Iunderstandand agreethat theterm “foreign national”

means anindividual whois not a United States citizen.

8. TheCompany[has] [has no] (circle one) foreignnational employees that require access to the requestedCONTROLLED UNCLASSIFIEDINFORMATION. (If

answered in the affirmative,additional documentation willbe required forDOE review andapproval, which can beprovided bytheContractingOfficerupon request).

9. Iunderstand and acknowledgethat DOE is providing access tothe requested CONTROLLED UNCLASSIFIEDINFORMATION forthe specific purpose of respondingtoaRequest forProposals. Furthermore,Iunderstand and acknowledgethat Companyemployees approved to haveaccess to the requested information willcomplywith theduties and responsibilities identified herein.

10. Iunderstand and acknowledgethe Companyhas a continuingobligation with respect to therequestedCONTROLLED UNCLASSIFIEDINFORMATION.

11. Iunderstand and acknowledgethe Companymaybe contacted to verifythe statements made herein and that DOE mayvisit theCompanyto ensurethat properinformation securitypracticesarein placeand arebeing followed. The Companyagrees to cooperatefullyin DOE’seffort in this regard.

12. Mystatements in thisagreement formaretrue, complete and correct to thebest of myknowledge, information and belief. Theyaremadein goodfaith forthe purposeof obtainingaccess tothe Department ofEnergyHanford Mission Essential Services Contract (HMESC) Solicitation No. 89303318REM000007Controlled UnclassifiedInformation.Iunderstandand acknowledgethat aknowing and willful false statement in this form is punishable byfineor imprisonment or both, pursuant to 18 United States Code, Section 1001.

Name:

Title/Position:

Email:

Phone:

Name ofCompany:

Name ofOfferor:

MailingAddress

SignatureDate