Request Form: ViaSat Agile Access
Date: _______________
EXPORT CONTROL STATUS VERIFICATION
The purpose of this form is to assist in verifying your export control status. U.S. laws and regulations prohibit the unauthorized export of
restricted technology to certain persons. To comply with these legal requirements, ViaSat must ascertain whether an individual who may be
given access to restricted technology is a “foreign person” subject to these export control restrictions. Regardless of individual status, persons
directly employed by an entity not organized or incorporated in the U.S. will be treated as foreign persons for purposes of access to restricted
technology. Certain categories of persons, referred to as U.S. persons” who are employed by U.S. entities, are not considered foreign persons
and do not need export licenses before being allowed access to restricted technology. The list of documents contained in section 2b should be
used to verify someone is a U.S. person. If an individual whose export control status is being verified furnishes a document from the list in
section 2a and indicates their employer is incorporated or organized in the U.S. in section 1, the individuals is a U.S. person for export control
purposes, and does not need an export license before being given access to restricted technology. All others are provided access to restricted
technology only with appropriate U.S. government authorization. INSTRUCTIONS 1. Review and complete either section 2 or 3 (as appropriate),
sign, and date. You are required to furnish unexpired, original documents, except where noted. 2. If you are an external partner or employee of
ViaSat affiliate not incorporated in the U.S., you are also required to complete section 3. 3. A company Security representative or Human
Resources, or designee, inspects the documents, verifies the accuracy of the information provided below, and certifies.
Section 1 - To be Completed by Applicant
1. Last Name, First Name and Middle Initial
3. Company Name and Applicant’s Site Address (Please Include
2. Work Phone
Internal Company Mail Routing Point if Applicable)
4. Applicant’s Business/Company Email Address
6. I have been COMSEC briefed
 YES
5. Applicant’s Title
 NO
(If YES is checked, you must indicate the COMSEC Account # in Section 6)
I have been FOUO briefed  YES
 NO
(if YES is checked, FOUO NDA must be on file with ViaSat)
7. Account Action Requested (Check One Box)  New
Revise Suspend Cancel Reinstate (Account Name)________________________________
8. Justification for Access
9. ViaSat Point of Contact:
Section 2 - Citizenship Verification
1.
Country of
Citizenship
2. Country of Residence
CHECK IF THIS SECTION APPLIES TO YOU 
3. Dual Citizenship?  Yes  No If Yes, List all other countries:
A. U.S. CITIZENS
 Unexpired United States passport or passport card
B. NON U.S. CITIZENS (U.S. Persons)
 Unexpired temporary resident card (USCIS Form 1-688, not 1-688A or 1688B)
 Certificate of United States citizenship (USCIS form N-560 or N-561)
 Unexpired re-entry permit (USCIS Form I327)
 Certificate of naturalization (USCIS Form N-550 or N-570)
 Unexpired refugee travel document (USCIS Form I-571)
 Certificate of birth abroad issued by the U.S. Department of State (Form
FS-545 or
DS-1350) or Report of Birth Abroad (FS-240)
 Alien registration receipt card with photograph (USCIS Form I-551 or I-151
 Original or certified copy of a birth certificate issued by a state, county,
 Unexpired foreign passport with I-551 stamp
municipal authority, or outlying possession of the United States, bearing an
official seal
 U.S. citizenship status confirmed in JPAS. Note: This option may ONLY be
used by U.S. government security or human resources representatives in
verifying the citizenship of U.S. government employees, and is not for use by
or for contractor personnel.
PR001100 Rev 009
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ViaSat Proprietary Data
CHECK IF THIS SECTION APPLIES TO YOU --
2. Country of Birth
Section 3 - For Non-U.S. Persons
1. Country of Citizenship
3. Dual Citizenship? Yes No If Yes, List all other countries:
4. Unexpired foreign passport (with I-94 if available)
Expiration Date
5. Other Non-U.S. document establishing country of citizenship*
Expiration Date
6. Specify Type of Document
Section 4 - Computer System User Acknowledgement Statement
I understand that ViaSat considers access, data, programs, software and/or any other information stored in its automated information systems
or under its jurisdiction to be proprietary, even though such information may not be marked as such. I agree not to copy, use or disclose to
others any such information without prior authorization of the owner of the information. Additionally, I understand that all activities associated
with ViaSat automated information systems, which includes my accesses and account(s), are subject to electronic monitoring. Furthermore, I
agree that I will: · Memorize my passwords and not display them where they may be compromised. · Not permit another individual to use my
User ID and password to obtain access. · Not use passwords that can be identified or directly attributed to me (such as common family names,
social security account numbers, telephone number or project names). Immediately notify the appropriate ViaSat management or point of
contact when I no longer require access to the automated information systems(s). · Immediately report any violation of automated information
system resource controls to the appropriate management or point of contact. · Periodically clear the browser cache and the contents of any
temporary directories to which data may have been copied while accessing a ViaSat automated information system. · I validate that my
computing device is configured to launch a password-protected screensaver after no more than 10 minutes of inactivity. I understand that
failure to abide by the above may result in disciplinary action, termination of my access to ViaSat automated information system(s), prosecution
under 18 USC 1905 and other action as deemed appropriate by ViaSat. By my physical or electronic signature below, I acknowledge that, as a
user of a ViaSat computer system, it is my responsibility to comply with all measures necessary to prevent unauthorized disclosure,
modification or destruction of information. I acknowledge and accept the computer usage statements above.
Applicant Signature:____________________________________________ Date:______________________
Section 5a - Computer System User Acknowledgement Statement
Section 5 – Point of Contact Ownership & Acknowledgement: ti-on 5a - Computer System User Acknowledgement
Statement
The Supplier Point of Contact listed below (POC); will be responsible for requesting named accounts for all employees at your facility and for
ensuring your employees do not share their credentials with others. The POC is also responsible for facilitating requests for additional accounts,
when required, and must promptly notify ViaSat when your employees no longer require access to the Agile system. The POC will also assist
with ViaSat’s audit of your facility’s Agile access by confirming the list of employees on a periodic basis.
As the company’s Point of Contact with ViaSat, I concur that the above listed employee requires network access as needed for the purposes of
quotations or to fulfill contractual obligations of existing purchase orders.
Is your company incorporated or organized in the U.S.?
 Yes No If “No”, please identify country:_____________________________
POC Name (print)______________________________________ POC E-Mail Address: ______________________________________
Signature:_______________________________________________Date:__________
(Note: Maximum of 15 users per supplier site, if more are required, please contact your ViaSat Supply Chain POC)
n
Company has an active COMSEC account – COMSEC Account # ______________________
COMSEC Briefing  YES
 NO
(If YES is checked, you must indicate the COMSEC Account # above)
I verify that the the applicant handling Comsec material meets the eligibility requirements and has received a Comsec or Cryptographic
briefing prior to access. This briefing is in accordance with the National Security Agency NSA/CSS Policy Manual 3-16
FOUO Briefing
 YES
 NO
I verify that the applicant handling FOUO material has been briefed on ViaSat’s FOUO Requirements per the FOUO NDA
5 - Computer System User Acknowledgement Statement
Security Validation (Applicant’s Security Officer)
(
Print Name
Applicant’s Security Office - if other than a company Security Officer,
Applicant’s Security Office - if other than a company Security Officer,
please indicate organizational title
)
Phone
Signature:
By signing this form I have validated that all the information is true and accurate.
Please E-mail completed form to your ViaSat Supply Chain Contact
or Fax to: (760) 929-3924 Mail to: ViaSat, 6155 El Camino Real, Carlsbad, CA 92009
PR001100 Rev 009
Page 2 of 6
ViaSat Proprietary Data
Instructions for Completing PR001100 Form
Use the Sample Form Below with the letters on it corresponding to each step in the Instructions
Below:
1
Supplier shall include on the Agile form (PR001100)
A. Current Date
B. Section 1.1- Last Name, First Name and Middle Initial
C. Section 1.2- Work Phone Number
D. Section 1.3- Company Name and Applicant’s Site Address
E. Section 1.4- Applicant’s Business/ Company e-mail address
F. Section 1.5- Applicant’s Title
G. Section 1.6- COMSEC and FOUO information:
a. If supplier has COMSEC account and was briefed on COMSEC by supplier’s COMSEC custodian - select
“YES” for COMSEC
b. Suppliers that do not have COMSEC account -select “NO” for COMSEC
c. If supplier has only Standard NDA with ViaSat – select “NO” for FOUO
d. If supplier has FOUO NDA with ViaSat and was briefed on FOUO by supplier’s Security Officer or HR- select
“YES “ for FOUO
H. Section 1.7- Account name and account action
I.
Section 1.8- Access Justification
J. Section 1.9-ViaSat Point of Contact
K. Section 2.1- Applicant’s Country of Citizenship
L. Section 2.2- Applicant’s Country of Residence
M. Section 2.3-Dual Citizenship information ( if applicable)
N. Section 2-A- U.S. Citizens information:
a. If applicant is U.S. citizen- one of the options must be selected in this section
O. Section 2-B- Non U.S. Citizens ( U.S. Persons) information:
a. If applicant is not a U.S. citizens, but a legal U.S. resident – one of the options must be selected in this section
P. Section 3- Non U.S. Person information - if applicant is Non U.S. citizen or resident the following information must be
provided:
a. Section 3.1-country of Citizenship
b. Section 3.2- Country of Birth
c. Section 3.3-Dual citizenship information ( if applicable)
d. Section 3.4- Unexpired foreign passport #
or
e. Section 3.5- Other Non-U.S. document information establishing country of citizenship
f.
Section 3.6- Document Type Specification
PR001100 Rev 009
Page 3 of 6
ViaSat Proprietary Data
Q. Section 4- Applicant’s Signature and current Date
R. Section 5- Supplier’s Point of Contact Information:
a. Country where supplier’s company was founded
b. Supplier’s Agile POC’s name
c. Supplier’s Agile POC’s e-mail address
d. Supplier’s Agile POC’s signature
e. Current date
S. Section 6- To be completed by applicant’s company Security Officer or HR (Human Resources) Representative.
a. Supplier’s COMSEC account # ( if applicable)
b. COMSEC information- supplier’s Security Officer or HR has to validate the COMSEC information by selecting
option “YES” or “NO” in section 6.
c. FOUO information- supplier’s Security Officer or HR has to validate FOUO information by selecting option
“YES” or “NO” in section 6.
COMSEC and FOUO information in section 1.5 and 6 has to match.
d. Security Officer’s Signature- supplier’s Security Officer has to validate the information by signing the
application in section 6.
e. If supplier’s company does not have Security Officer, then HR representative has to validate the information
indicated on the Agile application and sign the form in section 6.
PR001100 Rev 009
Page 4 of 6
ViaSat Proprietary Data
Request Form: ViaSat Agile Access
A-Date: _______________
EXPORT CONTROL STATUS VERIFICATION
The purpose of this form is to assist in verifying your export control status. U.S. laws and regulations prohibit the unauthorized export of
restricted technology to certain persons. To comply with these legal requirements, ViaSat must ascertain whether an individual who may be
given access to restricted technology is a “foreign person” subject to these export control restrictions. Regardless of individual status, persons
directly employed by an entity not organized or incorporated in the U.S. will be treated as foreign persons for purposes of access to restricted
technology. Certain categories of persons, referred to as U.S. persons” who are employed by U.S. entities, are not considered foreign persons
and do not need export licenses before being allowed access to restricted technology. The list of documents contained in section 2b should be
used to verify someone is a U.S. person. If an individual whose export control status is being verified furnishes a document from the list in
section 2a and indicates their employer is incorporated or organized in the U.S. in section 1, the individuals is a U.S. person for export control
purposes, and does not need an export license before being given access to restricted technology. All others are provided access to restricted
technology only with appropriate U.S. government authorization. INSTRUCTIONS 1. Review and complete either section 2 or 3 (as
appropriate), sign, and date. You are required to furnish unexpired, original documents, except where noted. 2. If you are an external partner or
employee of ViaSat affiliate not incorporated in the U.S., you are also required to complete section 3. 3. A company Security representative or
Human Resources, or designee, inspects the documents, verifies the accuracy of the information provided below, and certifies.
Section 1 - To be Completed by Applicant
1. Last Name, First Name and Middle Initial-B
2. Work Phone -
4. Applicant’s Business/Company Email Address:
5. Applicant’s Title:
E
F
6. I have been COMSEC briefed
 YES G
-a
 NO G
-b
C
3. Company Name and Applicant’s Site Address (Please
Include Internal Company Mail Routing Point if Applicable)
D
(If YES is checked, you must indicate the COMSEC Account # in Section 6)
I have been FOUO briefed  YES G
-d
 NO G -c (if YES is checked, FOUO NDA must be on file with ViaSat)
7. Account Action Requested (Check One Box)  New
Revise Suspend Cancel Reinstate (Account Name)____ H ____________________________
8. Justification for Access
I
9. ViaSat Point of Contact:
J
Section 2 - Citizenship Verification
2.
Country of
Citizenship
K
2.Country of Residence
CHECK IF THIS SECTION APPLIES TO YOU 
3. Dual Citizenship?  Yes  No If Yes, List all other countries:
L
M
A. U.S. CITIZENS N -a
 Unexpired United States passport or passport card
B. NON U.S. CITIZENS (U.S. Persons) O-a
 Unexpired temporary resident card (USCIS Form 1-688, not 1-688A or 1688B)
 Certificate of United States citizenship (USCIS form N-560 or N-561)
 Unexpired re-entry permit (USCIS Form I327)
 Certificate of naturalization (USCIS Form N-550 or N-570)
 Unexpired refugee travel document (USCIS Form I-571)
 Certificate of birth abroad issued by the U.S. Department of State (Form
FS-545 or
 Alien registration receipt card with photograph (USCIS Form I-551 or I-151
DS-1350) or Report of Birth Abroad (FS-240)
 Original or certified copy of a birth certificate issued by a state, county,
municipal authority, or outlying possession of the United States, bearing an
official seal
 Unexpired foreign passport with I-551 stamp
 U.S. citizenship status confirmed in JPAS. Note: This option may ONLY be
used by U.S. government security or human resources representatives in
verifying the citizenship of U.S. government employees, and is not for use by
or for contractor personnel.
PR001100 Rev 009
Page 5 of 6
ViaSat Proprietary Data
Section 3 - For Non-U.S. Persons
P-a
1. Country of Citizenship
CHECK IF THIS SECTION APPLIES TO YOU --
2. Country of Birth
3. Dual Citizenship? Yes No If Yes, List all other countries:
4. Unexpired foreign passport (with I-94 if available)
P-c
Expiration Date
P-d
5. Other Non-U.S. document establishing country of citizenship*
6. Specify Type of Document
P-b
P-e
Expiration Date
P-f
Section 4 - Computer System User Acknowledgement Statement
I understand that ViaSat considers access, data, programs, software and/or any other information stored in its automated information systems or
under its jurisdiction to be proprietary, even though such information may not be marked as such. I agree not to copy, use or disclose to others
any such information without prior authorization of the owner of the information. Additionally, I understand that all activities associated with
ViaSat automated information systems, which includes my accesses and account(s), are subject to electronic monitoring. Furthermore, I agree
that I will: · Memorize my passwords and not display them where they may be compromised. · Not permit another individual to use my User ID
and password to obtain access. · Not use passwords that can be identified or directly attributed to me (such as common family names, social
security account numbers, telephone number or project names). Immediately notify the appropriate ViaSat management or point of contact
when I no longer require access to the automated information systems(s). · Immediately report any violation of automated information system
resource controls to the appropriate management or point of contact. · Periodically clear the browser cache and the contents of any temporary
directories to which data may have been copied while accessing a ViaSat automated information system. · I validate that my computing device
is configured to launch a password-protected screensaver after no more than 10 minutes of inactivity. I understand that failure to abide by the
above may result in disciplinary action, termination of my access to ViaSat automated information system(s), prosecution under 18 USC 1905
and other action as deemed appropriate by ViaSat. By my physical or electronic signature below, I acknowledge that, as a user of a ViaSat
computer system, it is my responsibility to comply with all measures necessary to prevent unauthorized disclosure, modification or destruction of
information. I acknowledge and accept the computer usage statements above.
Applicant Signature:________Q____________________________________ Date:___________
Q ___________
Section 5a - Computer System User Acknowledgement Statement
Section 5 – Point of Contact Ownership & Acknowledgement: ti-on 5a - Computer System User Acknowledgement
Statement
The Supplier Point of Contact listed below (POC); will be responsible for requesting named accounts for all employees at your facility and for
ensuring your employees do not share their credentials with others. The POC is also responsible for facilitating requests for additional accounts,
when required, and must promptly notify ViaSat when your employees no longer require access to the Agile system. The POC will also assist
with ViaSat’s audit of your facility’s Agile access by confirming the list of employees on a periodic basis.
As the company’s Point of Contact with ViaSat, I concur that the above listed employee requires network access as needed for the purposes of
quotations or to fulfill contractual obligations of existing purchase orders.
Is your company incorporated or organized in the U.S.? R-a
 Yes No If “No”, please identify country:_____________________________
POC Name (print)_____R-b_________________________________ POC E-Mail Address: ______R-c____________________________
Signature:___________________R-d____________________________Date:_____ R-e_____
(Note: Maximum of 15 users per supplier site, if more are required, please contact your ViaSat Supply Chain POC)
n
Company has an active COMSEC account – COMSEC Account # ____S-a__________________
COMSEC Briefing  YES
 NO
(If YES is checked, you must indicate the COMSEC Account # above)
I verify that the applicant handling Comsec material meets the eligibility requirements and has received a Comsec or Cryptographic
briefing prior to access. This briefing is in accordance with the National Security Agency NSA/CSS Policy Manual 3-16
S-b
FOUO Briefing
 YES
 NO
I verify that the applicant handling FOUO material has been briefed on ViaSat’s FOUO Requirements per the FOUO NDA
S-c
5 - Computer System User Acknowledgement Statement
Security Validation (Applicant’s Security Officer)
(
Print Name
Applicant’s Security Office - if other than a company Security Officer,
Applicant’s Security Office - if other than a company Security Officer,
please indicate organizational title
)
Phone
S-e
S-d
Signature:
By signing this form I have validated that all the information is true and accurate.
PR001100 Rev 009
Page 6 of 6
ViaSat Proprietary Data