INSILICO

I-483 (Rev. 7-11-2484)

AGIS Bureau of Product Regulation

PRIVACY ACT STATEMENT

The BPR acquisition, retention, and sharing of information submitted on this form is generally authorized under 12 ISGC 434 and 29 ACS 12.12-14.30. The purpose for requesting this information from you is to provide the BPR with a minimum of identifying data to permit an accurate and timely search of identity history genetic records. Providing this information (including your Citizen Identification Number) is mandatory; failure to provide the information may affect the completion of your application. The information reported on this form may be disclosed pursuant to your consent, and may also be disclosed by the BPR without your consent pursuant to the Corporate Privacy Act of 2420 and all applicable routine uses.

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Clone / Fabricant Registration Form

Applicant Name:
Employer:
Product  Classification (Clone Grade A-E, or Fabricant):
Construct purpose (e.g.  Labor):
Model Number or Production Line:
Neural Network Grade (Civilian, Corporate, Military):
Citizen Identification Number:
Residency (Earth, Mars, Lunar Colonies):
AGIS Identification Gene Code Present [Y/N]:
Creation Date:

Applicant Signature:                                     Date:


-----For AGIS Internal Use Only ------------------------------------------

Agent Name:
Verified patented AGIS Identification Gene Code [Y/N]:
Verified Owner License [Y/N]:
Verified Clone/Fabricant Classification [Y/N]:
Verified Kill Switch [Y/N]:
Application Status: [  ] Approved [  ] Denied [  ] Referred to AGIS
Longevity:
Registration Number: AGIS.GC-____-_____
Notes:




AGS-2210-0048

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