SALS Full Compliance Attestation
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This article is under construction and should not be considered complete.
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This is Appendix A to the SALS Application Instructions and Attestation Forms.
| Please Note: |
| When submitted to IDESG, the Attestation must be provided on the PDF form downloadable from this page, and must be signed. All sections of the Attestation marked as mandatory by a double asterisk (" ** ") must be completed: submitted forms with information missing in those fields will be rejected. |
| This Web page version is provided for the convenience of readers only. The definitive current text for this document is the PDF download provided here: DOWNLOAD LINK: Full Compliance Attestation (with instructions) |
| Bracketed numbers ("<1>") in this Appendix are for reference, and are cross-indexed to the index numbers in the data elements list in Appendix 1 to the SALS Data Handling and Use Policy, and are not present on the PDF form provided for official submissions. |
Part 1. Reporting Entity ("Service Provider") Information
Name of Service Provider: ** <1>
Service Provider’s Physical Address: **
- Street Address: <2a>
- City: <2b>
- State/Province: <2c>
- Country: <2d>
- Postal Code: <2e>
Check box if mailing address is same as physical address: ____
Mailing Address ** (If mailing address is different than business address:)
- Street Address or Box: <3a>
- City: <3b>
- State/Province: <3c>
- Country: <3d>
- Postal Code: <3e>
Provider’s General Telephone: <4>
Provider Email: <5>
Provider URL:** <6>
Identity Service-specific URL to be referenced, if any: <7>
- - - - - - - -
Point of Contact ("PoC") for application information:
PoC Name: ** <8>
PoC email: ** <9>
PoC Telephone: ** <10>
- - - - - - - -
DUNS Number:** <11>
or No DUNS Number: Check box: ___
If no DUNS Number, then:
- Jurisdiction of Registration or Legal Formation (State/Locality): ** <12a>
- Date of Registration or Legal Formation: ** <12a>
- Government-assigned Registration, Incorporation, or Business License Number: <12c>
- - - - - - - -
Applicant Service Description: (at applicant's option, for inclusion in any listing: 200 Word Limit) <13>
- - - - - - - -
Please provide any needed explanations regarding unavailable information here:
- - - - - - - -
Part 2. Assessed Services:
Applicant provides the following types of identity management activities or services assessed in this report:
| ** Check all that apply | ||
| a. | Registration | __ <14a> |
| b. | Credentialing | __ <14b> |
| c. | Authentication | __ <14c> |
| d. | Authorization | __ <14d> |
| e. | Transaction Intermediation | __ <14e> |
(See the IDEF Glossary DIGITAL IDENTITY MANAGEMENT FUNCTIONS for more information on each function.)
Part 3. Self-Assessment Information
Self-Assessor Name:** <15>
Self-Assessor Title:** <16>
Email:** <17>
Telephone: ** <18>
Part 4. Self-Assessment Report Date
Assessment Completion Date:** <19>
Please note: This must match the date on the Self-Assessment Matrix. (This is the date "as of" which your information will be reported to be current. Information submitted in the application must be current as of this date.
A completed Self-Assessment Matrix MUST be attached to or delivered with this form, in order to make a valid complete submission.
All of the applicable Requirements listed in the attached Matrix have been satisfied, as noted on the Matrix.
Please check one: ** <20>
____ Yes
____ No
If No, please explain why the Provider is applying for inclusion in the Listing Service:
Part 5. Agreement
I confirm as of the date indicated below that the information provided on this IDESG SALS Full Compliance Attestation and in the attached Self-Assessment Matrix indicates the successful implementation of the Baseline Requirements for the identity services indicated above. This confirmation is made to the best of my knowledge from the results of the self-assessment process and other information available to me relating to the service(s) assessed.
My signature below also indicates my acknowledgment that I have read and that I agree to the SALS Supplemental Terms of Use, which apply to the Self-Assessment Listing Service, and that I have been authorized by the organization named below to agree to these terms.
Signature: __<21>________________________________
Name (in text)_<22>________________________________
Position/Title: __<23>_____________________________
Date:__<24>____________
On behalf of: __<1>_______________________________ (Insert name of "Provider" here)
| >> | Forward to: | Appendix B: SALS Status Report Attestation Form |
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