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-7- Attachment A Cabarrus County Application for Approval of Tier I Registration for Licensed Professional to Obtain and Use Sensitive Infrastructnre Data This is a request by LICENSED PROFESSIONALS authorizing representatives of their company to obtain sensitive maps, plans, data, and other engineering information pertaining to the County's public infrastructure systems for their use in the practice of their profession, as per the County's Infrastructure Confidentiality and Security Policy, Section 3.2. Please attach a detailed description of the information reqnested and its intended use. Category ofInformation Requested (Select Only One Per Form): _ Public Buildings _ Telecommunication and Data Network Systems _ Public Security Plans I hereby designate the following individuals of our organization to make requests for information as described above. As a condition of this approval we will immediately notifY COUNTY, in writing, if any of these employees are terminated or otherwise not authorized to obtain information under this agreement. We may add employees in a similar manner. Employees Authorized (Please Print): (If more names are needed, please attach a second sheet.) I hereby agree that any material furnished to onr company will not be copied for transmittal to any other company or individual outside our company. Approval of this request is conditional npon reading and accepting the terms of the Connty's Infrastructure Confidentiality and Security Policy, including contract termination, limits upon future work and payment of damages, if any. I understand and agree that the Cabarrus County provides no warranties of any kind about the data provided. NAME OF REQUESTING FIRM: ADDRESS: REQUESTED AND AUTHORIZED BY: . (Printed Name) (Title) (Signature) (Date of Request) (NC Professional License Number) COUNTY ApPROVED BY: (Name) (Title) (Date Approved) I":.. I~