Primary + Open Data Challenge: Contact Information Form

U.S. DOT Intersection Safety Challenge – System Assessment and Virtual Testing Competition

Contact Information Form

Primary + Open Data Challenge: Contact Information Form

OMB: 2125-0678

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OMB Control No. 2125-XXXX

Expiration Date: MM/DD/YYYY



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Intersection Safety Challenge Stage 1B Contact Information Form


  1. Team Lead: Provide one Team Lead, which can be an organization or an individual who is participating in the team in an individual capacity, i.e., not representing an organization. Note: For Primary Track participants, the Team Lead must be the same as the team lead listed in Stage 1A.


    1. Team Lead:


  1. Team Lead point of contact (POC): Provide one POC for the team. If the Team Lead is an organization, name a specific POC within that organization; if the Team Lead is an individual, provide contact information for that individual. Note: For Primary Track participants, the Team Lead POC does not need to be the same as the Team Lead POC listed in Stage 1A.


    1. Name:

    2. Role/title:

    3. Email:

    4. Phone Number:


  1. Official Team Members: List all Official Team Members, including organizations and individuals who are participating in the team in an individual capacity, i.e., not representing an organization. List addresses for all Official Team Members.


Organization or Individual Name

Address

State of Incorporation (if applicable)














  1. For teams that include organizations as Official Team Members:

    1. I certify that all official team member organizations, listed above, are incorporated in and maintain a primary place of business in the United States.

      • Yes

      • No

      • N/A (no organizations as Official Team Members)


  1. For teams that include individuals participating in an individual capacity as Official Team Members:

    1. I certify that all official team member individuals, listed above, are citizens of the United States or permanent residents of the United States.

      • Yes

      • No

      • N/A (no individuals as Official Team Members)



Submitter Name:


Signature:


Date:

Form No.: ?????

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorDolan, Alissa (FHWA)
File Modified0000-00-00
File Created2023-11-08

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