ACCESS REQUEST Form

Thank you for submitting a request form. We will be sending you an email shortly with a copy of your request. Make sure to keep a copy. Check your spam folder if you don't see our email. Make sure to put our email in your inbox to make sure you get our emails. Thanks so much! MIRaGE Team

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*First Name

*Last Name

*Email

*UsernameAs displayed on the computer MIRaGE will be installed on. To find the username on the platform where you will be running MIRaGE, launch a Command Prompt Window (or terminal) and type 'whoami' at the prompt. (Depending on your system, you will see either just the username or both the domain and username displayed.)

*Phone Number

Industry

*Company Name

Country

Intended Usage

1.0 Please provide information for our long-term records and communications with your company/agency.

1.1 Company/Agency Name:

*DUNS Number:If you are a government agency and are not required to have a duns number just put 0000

*Address for Overnight Delivery:

*City:

*Zip/Postal Code:

*State:

*Phone:

*Country:

Fax:

1.2Parent Company (if applicable):

2.0 Please provide (if applicable) the pertinent information for the division in your company/agency with whom Sandia National Laboratories will be working.

*If Part 2 is not completed, then Parts 3-12 will apply to the entity listed in Part 1.

Is it the same as before?

Yes

Division Name:

Address for Overnight Delivery:

City:

Zip/Postal Code:

State:

Phone:

Country:

Fax:

Industry Classification:

3.0 Please provide the company/division or agency name as you want it to appear on the agreement.

4.0 Please provide specific points of contact within your company/division or agency.

4.1 Please provide the technical point of contact with whom our technical staff will be working.

*Is this the same as before?

Yes

Title

Dr.

Mr.

Mrs.

Ms.

Name

Email:

Address for Overnight Delivery:

City:

Zip/Postal Code:

State:

Phone:

Country:

Fax:

4.2 This agreement may involve the negotiation of legal and/or business terms and conditions between your company/division or agency and Sandia National Laboratories. Please provide the non-technical point of contact for questions (e.g. corporate/agency attorney, contracts manager, etc.).

Title

Dr.

Mr.

Mrs.

Name

Email:

Address for Overnight Delivery:

City:

Zip/Postal Code:

State:

Phone:

Country:

Fax:

4.3 Please provide contact information of the individual with signing authority for your company/division or agency.

Title

Dr.

Mr.

Mrs.

Ms.

Name

Email:

Address for Overnight Delivery:

City:

Zip/Postal Code:

State:

Phone:

Country:

Fax:

*4.4 Which party should we use as our primary point of contact?

Technical

Non-Technical

Signatory

5.0 Provide information for the company/division or agency listed in Part 1 or 2.

Disregard Part 5 if the entity listed in Part 1 or 2 is a government

NOTE: 5.1, 5.2, 5.4, and 5.5 must be answered.

5.1

A U.S.-owned business

A non U.S.-owned business

5.2

A U.S.-controlled business

A non U.S.-controlled business

5.3

A multi-national company (i.e., U.S.-owned with foreign research and/or manufacturing facilities)

5.4

State of Incorporation:

Country of Incorporation:

5.5 Does the company/division have operations in the United States?

Yes

6.0 Will MIRaGE exclusively be used in the United States?

Yes

7.0 Are all employees and subcontractors of the company/division or agency listed in Parts 1 and 2 who will be receiving information and/or intellectual property from Sandia National Laboratories under this proposed agreement CITIZENS OF THE UNITED STATES?

Yes

7.1If 7.0 is NO, of what countries are the recipients a citizen? (Attach additional information sheets to list all applicable recipients/countries if necessary)

8.0 Are any employees of the company/division or agency listed in Parts 1 and 2 who are involved in negotiating this agreement either current or former (“former” meaning within the last 6 months) employees, consultants, or contractors of:

8.1 NTESS, LLC?

Current

Former

8.2 Honeywell International, Inc. or its named businesses?

Current

Former

8.3 Kansas City National Security Campus/ Honeywell Federal Manufacturing and Technologies (FM&T)?

Current

Former

8.4 Nevada National Security Site/Mission Support and Test Services (MSTS)?

Current

Former

8.5 Savannah River National Laboratory/ Savannah River Nuclear Solutions (SRNS)?

Current

Former

8.6 Plymouth Trusted Foundry?

Current

Former

8.7 Northrup Grumman?

Current

Former

8.8 Universities Research Association, Inc. (URA)?

Current

Former

8.9 Longenecker and Associates, Inc.?

Current

Former

8.10 Sandia Technical Partners (STP) and its member companies?

Current

Former

8.11 The Department of Energy?

Current

Former

Name the individual(s) and associations, if any, on an attachment.

9.0 The company/division or agency listed in Part 2 is a(n) (check all that apply):

9.1U.S.-owned business meeting criteria of a small business under those defined by the US Small Business Administration https://sba.gov/

Yes

9.2Large business (500 or more employees)

Yes

9.3Non-profit organization or business under the U.S. Internal Revenue Code

Yes

9.4Consortium or member of a consortium or partnership under the potential agreement

Yes

9.5Formed as a joint venture

Yes

9.6Trade association

Yes

9.7Honeywell International, Inc. or its wholly owned subsidiaries including Federal Manufacturing and Technologies, currently known as the Kansas City National Security Campus, and Honeywell Automation and Controls Sustainable Technologies

Yes

9.8U.S. local government entity

Yes

9.9U.S. state government entity

Yes

9.10U.S. federal government agency

Yes

9.11Contractor to a U.S. federal government agency requesting access to Sandia National Laboratories intellectual property for use on behalf of the U.S. government

Yes

9.12U.S. institution of higher education (please specify below)

Yes

State-chartered institution

Private institution

9.13Department of Energy National Laboratory

Yes

9.14Historically black college or university

Yes

9.15Certified 8A firm

Yes

9.16Disadvantaged business

Yes

9.17Woman-owned business

Yes

9.18Minority-owned business

Yes

9.19Native American-owned business

Yes

9.20Hispanic American-owned business

Yes

9.21African American-owned business

Yes

9.22Asian American-owned business

Yes

9.23Tribal government

Yes

9.24Foreign company/government entity

Yes

9.25None of the above (explain on a separate sheet)

9.26If 9.4, 9.5, or 9.6 is checked, is the signatory to this agreement authorized to bind all members of the consortium, partnership, joint venture, or trade association to the terms and conditions in the proposed agreement?

Yes

9.27
If 9.11 is checked, please fill in all fields below. If 9.13 is checked, fill in the contract number and contract start/end dates.

U.S. federal government agency:

Federal contract number:

Contract start and end dates:

Government agency contact:

Phone Number

10.0Is either the company/division or agency listed in Parts 1.0 and 2.0 debarred, suspended, or ineligible as defined in the Federal Acquisition Regulation 9.4?

Yes

If yes, identify the agency (e.g., DOE, NIH, etc.):

By submitting this form, I attest that the information provided is correct as of this date and may be relied upon for purposes of entering into the proposed agreement.

*Name

Title

*Date

*Signature