Form of the organization

(for the legal entity)

Federal Service

on engineering and export supervision

Old Basmannaya st., 17,

Moscow, 105066

Ref. from __________ 20 __.

№____________________

Statement

about provision of license for activities on technical protection of confidential information to the legal entity

I ask to provide

(the complete and reduced (in the presence) name of the legal entity, its form of business)

license for activities on technical protection of confidential information on the following work types and (or) services:

.

(work types and (or) services, stipulated in Item 4 Provisions on licensing of activities for technical protection of confidential information, No. approved by the order of the Government of the Russian Federation of February 3, 2012 79, which the legal entity intends to perform)

The address within the location of the legal entity:

Addresses of places of implementation of the licensed type of activity:

,

The address for correspondence:

.

(postal address of the legal entity)

Phone (the fax in the presence) with indication of city code

.

E-mail address (in the presence):

.

Primary State Registration Number (PSRN):

,

date:

.

(data of the document confirming the fact of entering of information about the legal entity into the Unified State Register of Legal Entities)

Identification Taxpayer Number (ITN):

,

.

(data of the document confirming the fact of statement of the legal entity on accounting in tax authority)

Details of the document confirming the fact of payment of the state fee for provision of the license, or other data confirming the fact of payment of the specified state fee: _______________________

.

Worker, representative for licensing:

.

(surname, name, middle name (in the presence), phone numbers)

Appendix:

1. The data confirming availability and qualification of personnel according to appendix No. 1 to this statement;

2. Data on availability in the place of implementation of the licensed type of activity of the protected rooms according to appendix No. 2 to this statement;

3. Data on availability of the automated systems certified for safety requirements of information which are in the protected room intended for storage and processing of confidential information according to appendix No. 3 to this statement;

4. The description of engineering procedure of processing of confidential information in the automated systems according to appendix No. 4 to this statement;

5. The list protected in the automated system of resources according to appendix No. 5 to this statement;

6. Data on the equipment necessary for accomplishment of the declared works and (or) rendering services when implementing activities for technical protection of confidential information, according to appendix No. 6 to this statement;

7. Data on technical and technological documentation, the national standards and methodical documents necessary for accomplishment, rendering the declared works, services when implementing activities for technical protection of confidential information, according to appendix No. 7 to this statement;

8. Other data and copies of documents which list is determined by the Regulations on licensing of activities for technical protection of confidential information approved by the order of the Government of the Russian Federation of February 3, 2012 No. 79;

9. The inventory of the documents enclosed to the application on ___ l. according to appendix No. 8 to this statement.

(the head of permanent executive body of the legal entity or the other person having the right to act on behalf of this legal entity)

(signature)

(initials, surname)

M.P.

(in the presence of seal)

Data,

confirmatory availability and qualification of the personnel performing activities for technical protection of confidential information

(name of the license applicant)

Professional categories

Surname, name, middle name (in the presence)

Including

with the higher education

with length of service in the field of the carried-out works on the licensed type of activity

trained according to programs of occupational retraining for one of specialties in information security field (at least 360 classroom hours)

in the direction of preparation (specialty) in information security field

in the direction of preparation (specialty) in the field of mathematical and natural sciences, engineering, technologies and technical science

other higher education

at least 3 years

at least 5 years

1

2

3

4

5

6

7

8

9

1

The head and (or) authorized to direct works on the licensed type of activity person

2

Engineering employee

3

Engineering employee

(the head of permanent executive body of the legal entity or the other person having the right to act on behalf of this legal entity)

(signature)

(initials, surname)

M.P.

(in the presence of seal)