Contact Information Form

OMB Control No. 2125-XXXX

Expiration Date: MM/DD/YYYY

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2125-XXXX. Public reporting for this collection of information is estimated to be approximately 15 minutes per response to complete, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, completing, and reviewing the collection of information.

All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Department of Transportation, 1200 New Jersey Ave SE, Washington, D.C. 20590.

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:

2. 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:

3. 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)

4. 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)

5. 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:

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