COMPANY INFORMATION Company Name Address 1 Address 2 City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code URL FEIN DUNS # Number of Employees Number of Employees in VA What % of sales are to defense agencies? Are you aware of new wording for DFARS requirements in your contracts? Yes No Have you defined the CUI you are currently responsible for? Yes No Have you completed an assessment of current compliance level? Yes No Unknown Do you have the required security plan in place to safeguard CUI? Yes No Unknown Please briefly describe your company's products and/or services. What would be the quantifiable impacts to your business if you are unable to maintain current DOD contracts? Have you taken any action to address the new DFARS requirements so far? PRIMARY POINT OF CONTACT Contact Name Contact Title Contact Email Address Contact Email Address Confirm email Contact Phone Number TERMS AND CONDITIONS All program benefits are delivered as services. At company's request, a proposal for service will be prepared for consideration. Company cost share for services will equal 20% cash (non-refundable) upon acceptance. Program will bear remainder. I am authorized to execute this application on behalf of my company. Submitter Name Submitter Title Today's Date Signature Please enter your initials here to act as your signature. All information will be kept CONFIDENTIAL and only used for program selection. Data will only be shared in aggregate form with no identifiable information provided. Submit Leave this field blank
