CISA Industry Engagement Intake Form

CYBERSECURITY
& INFRASTRUCTURE
SECURITY AGENCY

U.S. Department of Homeland Security
Cybersecurity & Infrastructure Security Agency
Washington, DC 20528

Vendor Engagement Questionnaire
Please complete the questions below and email this form/PDF file to cisaindustryengagement@cisa.dhs.gov.
Answer all questions as thoroughly as possible, as this information is used to help determine the suitability of your company’s capabilities to
future needs of CISA.
You may include a copy of your corporate capabilities statement as an Acrobat PDF, Microsoft Word, or Microsoft PowerPoint document.
Please limit the size of the attachments to no more than 5 MB.
(* Items appearing with a red asterisk are required for processing.)

SECTION 1: VENDOR BACKGROUND
1
2

Legal Business Name *
DBA Name (If Applicable)

3
4
5
6

Unique Entity Identifier (UEI)
6-digit NAICS Code *
Physical Address
Website URL

7

8

9

Name *
Title *

Primary Point of Contact

Phone *
Email *
Is your organization incorporated with a presence or business partner located in the United States? *
For-Profit: Other-Than-Small Business
For-Profit: Small Business
DHS Center of Excellence
Business Size or Type *

Yes

No

Federally Funded Research and Development Center (FFRDC)
Other Academic or University
Non-Profit Organization
State, Local, Tribal, and Territorial Governments
Woman-Owned
Veteran-Owned
Service-Disabled Veteran-Owned
Small Disadvantaged Business
8(a) Firm
HUBZone Firm

10 Socio-Economic Status *

SECTION 2: CAPABILITY SELECTION
11

Select up to five capabilities offered by your organization.
Use the additional open spaces if you would like to suggest capabilities that are not listed.

Privacy Act Statement
Authority: 5 U.S.C. § 301 and 44 U.S.C § 3101 authorize the collection of this information.
Purpose: The primary purpose for the collection of this information is to determine the suitability of your company's capabilities to the future needs of CISA. Routine Uses: The information collected may be
disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using the information as necessary and authorized by the routine uses published in DHS/
ALL-002 - Department of Homeland Security (DHS) Mailing and Other Lists System November 25, 2008, 73 FR 71659.
Disclosure: Providing this information is voluntary, however, failure to provide this information will prevent CISA from processing this questionnaire.

Paperwork Burden Notice:
The public reporting burden to complete this information collection is estimated at 30 minutes per form response, including the time for reviewing instructions, searching existing

data sources, gathering and maintaining the data needed, and the completing and reviewing the collected information. The collection of information is voluntary. An agency may
not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number and expiration date. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to DHS/CISA/OCAE, 245 Murray
Lane, SW, Mail Stop 0640, Arlington, VA 20598-0640 ATTN: PRA [OMB Control No. 1670-00XX].