[an error occurred while processing this directive]
[an error occurred while processing this directive]

Cubit Logo

Licensing

Sandia National Laboratories

Government Strategic Relationships Participant Data Sheet

ALL APPLICABLE SECTIONS MUST BE COMPLETED BEFORE SANDIA CAN PROCESS YOUR AGREEMENT.



1.0 In part 1, please provide corporate information for our long-term records and communications with your company.
1.1 Company Name/Government Agency Name:
Address for Overnight Delivery:
City: State: Country:
Zip/Postal Code: Area Code/Phone: Area Code/FAX:
1.2 Parent Company (if applicable):

2.0 In Part 2, Please provide (if applicable) the pertinent information for the Division in your company with whom Sandia will be working. If Part 2 is not completed, then Parts 3 through 9 will apply to the entity listed in Part 1.
Division Name:
Address for Overnight Delivery:
City: State: Country:
Zip/Postal Code: Area Code/Phone: Area Code/FAX:
Industry Classification:

3.0 Please provide the Company/Division/Government Agency name as you want it to appear on the agreement:

4.0 In part 4, please provide specific points of contact within your company.
4.1 Please provide the technical point of contact in your company with whom our technical staff will be working.
Mr.  
Ms. Name:
Address for Overnight Delivery: Email:
City: State: Country:
Zip/Postal Code: Area Code/Phone: Area Code/FAX:

4.2 Please provide the contact information for the individual who will be signing the agreement with Sandia.
Mr.  
Ms. Name:
Title:
Address for Overnight Delivery: Email:
City: State: Country:
Zip/Postal Code: Area Code/Phone: Area Code/FAX:

4.3 Which party should we use as our primary point of contact? Technical Legal/Business Agreement Signatory
NOTE: This is the party who will receive the final agreement for routing and signing.

5.0 Are all of the employees at the company/division listed in Parts 1 and 2 (or subcontractors to the company/division), who will be receiving information and/or intellectual property from Sandia under this proposed agreement CITIZENS OF THE UNITED STATES?     YES   NO
5.1 If 5.0 is NO, of what countries are the recipients a citizen (send additional information sheets, if necessry, to list all applicable recipients/contries):
Name: Country: U.S. Immigration Status:
Name: Country: U.S. Immigration Status:
Name: Country: U.S. Immigration Status:

6.0 Are any employees of the company/division listed in Parts 1 and 2, who are involved in negotiating this agreement, either current or former ("former" means within the last two years):
6.1 Sandia Employees?     Current   Former   No
6.2 Sandia consultants or contractors?     Current   Former   No
6.3 Lockheed Martin employees?     Current   Former   No
6.4 Department of Energy Employees?     Current   Former   No
Name the individual(s) and associations, if any, and send in the additional information sheets.

7.0 The company/division listed in Part 2.0 is (check all that apply):
7.1 A Lockheed Martin company
7.2 A local government entity
7.3 A state government entity
7.4 A U.S. government agency
7.5 A Dept. of Energy national laboratory
7.6 A contractor to a U.S. government agency requesting access to Sandia intellectual property for use on behalf of the U.S. Government
Federal Contract#:
Government Agency Name:
Contract Start Date:
Contract End Date:
Contract Name and Phone:



Name:
Title: Email:

By submitting this form to Sandia, 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.