Vendor's Legal Name


Vendor's Email Address


Name of the system for the title of the Certification Report


The Subsystem identifier uniquely defines the implementation of the subsystem such as a version or model number


Brief Description of the system under test


Details functional description including inputs, outputs, input interface description, output interface description, physical and logical boundaries, and security boundaries of the system.

* If an application provider has multiple versions of the application, all of which use the same code and controls for the functions that DEA is requiring, a single audit may be able to address multiple versions if other changes could not impact these functions.


The following will determine which requirements of the DEA's interim final rule will be audited for compliance.


yesno


yesno


yesno


yesno


yesno


yesno


yesno


yesno


yesno


yesno


yesno


yesno


yesno


Password
yesno
Hard token (verify compliance to FIPS 140-2 Security Level 1)
yesno
Biometrics (please identify the modality)
yesno