Authorized representatives notification

Document Name:	NIJ CTP Authorized Representative	Approval Date:	dd mmm yyyy
Revision:	21 Jun 2012	Implementation Date:	dd mmm yyyy
OMB Number:	1121-0321	Expires:	dd mmm yyyy

National Institute of Justice Compliance Testing Program
Authorized Representative Notification

In accordance with the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it displays a valid OMB control number. The OMB number for this collection is 1121-0321. Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information.

This information is being requested pursuant to 6 U.S.C. 162(b)(4) and 6 U.S.C. 162(b)(6)(B). The disclosure is voluntary. The information provided on this form will be used by the National Institute of Justice to administer a product conformity assessment program for products used by law enforcement and correctional officers. This information and the associated products are voluntarily submitted under the Compliance Testing Program.

PRIVACY ACT NOTICE: The information provided in this document is not considered Confidential Commercial Information and may be released without limitations or restrictions.

This National Institute of Justice Compliance Testing Program Authorized Representatives Notification pertains to all applicants seeking to voluntarily participate in the National Institute of Justice Compliance Testing Program (hereafter, the NIJ CTP). Any reference to the NIJ CTP as an organization includes elements of both National Institute of Justice (NIJ) and the National Law Enforcement and Corrections Technology Center-National (NLECTC-National).

Please provide business headquarters information below.

Applicant Name:

Applicant Address:

Telephone:

The Applicant hereby expressly acknowledges and agrees that the following Authorized Representatives are authorized to supply information concerning product submittals and surveillance on which the NIJ CTP may act:

Authorized Representatives

#1 (Name/Title):

#1 Telephone Number:

#1 E-mail:

#2 (Name/Title):

#2 Telephone Number:

#2 E-mail:

#3 (Name/Title):

#3 Telephone Number:

#3 E-mail:

#4 (Name/Title):

#4 Telephone Number:

#4 E-mail:

Applicant Signatory

(an officer or representative of the Applicant who has the authority to bind it)

(Name/Title):

Telephone Number:

E-mail:

The Applicant agrees to the terms of this agreement and warrants that it has made no alterations to its text. The undersigned represents and warrants that he/she is authorized to execute this agreement on behalf of the Applicant.

Applicant Signatory Date

NLECTC-National Representative Acknowledgement:

Signature Date

Name (Please print/type)