Authorized representatives notification

Document Name:
Revision:
OMB Number:

NIJ CTP Authorized Representative
07 Dec 2015
1121-0321

Approval Date:
Implementation Date:
Expires:

dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy

National Institute of Justice Compliance Testing Program
Authorized Representatives 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 (NIJ) to administer the NIJ Compliance Testing
Program (NIJ CTP), a conformity assessment program for products used by criminal
justice practitioners. This information and the associated products are submitted
voluntarily.
PRIVACY ACT NOTICE: The information provided in this document is not considered
Confidential Commercial Information and may be released without limitations or
restrictions.
This NIJ CTP Authorized Representative Notification is dated when signed by the
Applicant Signatory, and is between the Applicant and the Conformity Assessment Body
(“CAB”), which consists of both NIJ and the recipient of the Cooperative Agreement
Number 2014-IJ-CX-K004 issued by the Office of Justice Programs, NIJ.
The CAB implements the functions of the NIJ CTP, a program funded by NIJ, which in
turn is part of the U.S. Department of Justice (DOJ), Office of Justice Programs (OJP).
NIJ monitors and directs the administration of the NIJ CTP.
This agreement shall supersede all previous National Institute of Justice Compliance
Testing Program Authorized Representative Notifications between the Applicant and the
CAB.
Please provide business headquarters information below.
Applicant Name:
Applicant Address:

Telephone:

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Document Name:
Revision:
OMB Number:

NIJ CTP Authorized Representative
07 Dec 2015
1121-0321

Approval Date:
Implementation Date:
Expires:

dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy

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:

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Document Name:
Revision:
OMB Number:

NIJ CTP Authorized Representative
07 Dec 2015
1121-0321

Approval Date:
Implementation Date:
Expires:

dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy

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 and is signing this
agreement on the date stated opposite the Applicant’s signature.

Applicant Signatory

Date

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