Listee notification

Document Name:	NIJ CTP Listee Notification	Approval Date:	dd mmm yyyy
Revision:	20 Jun 2012	Implementation Date:	dd mmm yyyy
OMB Number:	1121-0321	Expires:	dd mmm yyyy

National Institute of Justice Compliance Testing Program
Listee 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).

Model Designation:

Date of Notification:

Please provide business headquarters information below.

Applicant Name:

Applicant Address:

Telephone:

Model Designation:

The Applicant hereby expressly acknowledges and agrees as follows:

Although it is not required that the Applicant has ownership of all brands or trademarks identified here, the Applicant warrants that it has permission from the owner (Listee) to engage in brand labeling of the product model identified above.

The NIJ CTP maintains a Compliant Products List (CPL) identifying models compliant with program requirements. Product listing includes model designation and Listee/Brand.

Other than the Listee information provided here and included on the label, no other changes are permitted.

Use of this form to identify multiple Listee status does not authorizes additional or alternative manufacturing locations.

The NIJ CTP shall hold the applicant responsible for actions they or the Multiple Listee(s) may take in regards to this model. Failure of the Applicant or additional Listee(s) to abide by the requirements of the NIJ CTP could have a negative impact on the Applicant’s continued participation in the NIJ CTP, up to and including the removal of all Applicant models from the CPL under any brand or trademark.

Final labeling shall be both controlled by and the responsibility of the Applicant.

Listee # 1:

Company:

Name

Address

Point of Contact:

Name

Title

Phone

E-mail

Trade Name/Brand

Model Designation:

Listee # 2:

Company:

Name

Address

Point of Contact:

Name

Title

Phone

E-mail

Trade Name/Brand

Listee # 3:

Company:

Name

Address

Point of Contact:

Name

Title

Phone

E-mail

Trade Name/Brand

Model Designation:

Applicant Signatory

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

(Name/Title):

Telephone Number:

E-mail:

□ additional pages have been attached (each page initialed and dated) to indicate additional manufacturing locations.

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 and the Multiple Listees referenced here.

Applicant Signatory Date

NLECTC-National Representative Acknowledgement:

Signature Date

Name (Please print/type)

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