Primary Information

Date Submitted

Product Evaluation#:

Manufacturer / Vendor

Name

Product Being Submitted for Recertification (Only products with a previous approval letter are eligible.)

Product Name:

Product Web Site:

The product has been sold to the following Districts (District’s Names, Date of Sale, and District’s POC are required):

Name of Special Specification used by the District(s) to use this product:

By completing the check boxes below, I acknowledge that I have fully read and understood the following:

I confirm that this product's name has not changed or been sold under a different name to TxDOT.

I confirm that the original submitting company's name has not changed.

I confirm that the product has not been modified or changed in any way since it was approved by TxDOT.

Electronic Signature:

Step 2 of 2

Contact

(person to be contacted to provide additional information or when the recertification is complete)

Name:

E-mail Address:

Mailing Address:

Telephone:

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