FedRamp Agency Request Form

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Requesting Agency

Agency Name *Street Address

CityStateZIP

Primary Contact

First Name *Last Name*Title*Phone*Email*

Secondary Contact

First Name *Last Name*Title*Phone*Email*

CSP Points of Contact

Primary Contact

First Name *Last Name*Title*Phone*Email*

Secondary Contact

First Name *Last Name*Title*Phone*Email*

CSP System Information

CSP Company Name *Provide a Short Description of the CSP System* Cloud Service Model *
Cloud Deployment Model

Public
Private
Hybrid
Community

FIPS-199 Categorization: *

Previous Authorizations

Has the system described above received an ATO from your agency or through a multi-agency contract vehicle?*
Date ATO was Granted (MM/DD/YYYY) Contract Vehicle (Not Required)

Third Party Assessor

Was an accredited 3PAO used during the process in which the CSP received an ATO?*
3PAO Company Name (Not Required)

Authorizing Representative Signature

As the authorizing representative, I am formally requesting FedRAMP security authorization for the cloud based system described in the document. The organization has reviewed the FedRAMP security and process requirement documents as posted on FedRAMP.gov and agrees to adhere to the conditions of completing the FedRAMP security assessment process and maintaining a FedRAMP provisional authorization if it is granted as a result of this process. Furthermore, I attest that all statements made in this application are correct to the best of my knowledge and are made in good faith.*