NORTH CAROLINA DEPARTMENT OF TRANSPORTATION NEW PRODUCT EVALUATION APPLICATION FORM FILL ALL LINES or MARK N

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NORTH CAROLINA DEPARTMENT OF TRANSPORTATION NEW PRODUCT EVALUATION APPLICATION FORM FILL ALL LINES or MARK N Powered By Docstoc
					                       NORTH CAROLINA DEPARTMENT OF TRANSPORTATION

                       NEW PRODUCT EVALUATION APPLICATION FORM
                                         (FILL ALL LINES or MARK N/A)


NOTE:-First Check NCDOT “Standard Specifications For Roads and Structures”.
Does your product meet this standard specification? If yes, list specifications Division/Section/
Articles. (attach explanation if necessary) here

and fill out only parts I & II below. Submit the form to process your request.
If no, complete and submit the entire form to process your request.

I. PRODUCT IDENTIFICATION                                            Submittal Date

Product Trade Name
Product Model Number
Brand Names
Product Web Site: www.

II.      PRODUCT CONTACT INFORMATION
                                                                           Phone No.
Manufacturer                                                               Fax No.
Contact Name                                                               Title
Address
                  Street                              City                         State             Zip Code
Email Address

                                                                           Phone No.
Distributor or Vendor                                                      Fax No.
Contact Name                                                               Title
Address
                  Street                              City                         State             Zip Code

Email Address

III.     PRODUCT MATERIAL DESCRIPTION

Identify the product


Primary use (must apply to highway usage with explanation provided)


Alternate use (must apply to highway usage with explanation provided)


Availability:   Seasonal           Non Seasonal              Delivery at site          Weeks after receipt of order.

Does product have hazardous materials?     Yes       No              Describe:

Does product have recycled materials?      Yes       No              Identify %:




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                      NEW PRODUCT EVALUATION APPLICATION FORM
                                            (FILL ALL LINES or MARK N/A)


III.        PRODUCT MATERIAL DESCRIPTION (cont.)

Alternate or comparison to existing product(s)

Product advantages – limitations

Additional Information

Outstanding features or benefits


Material composition or formulation


Is product warranted?     Yes                No               If yes, submit copies of all applicable warranties.

Conditions not warranted.

Material specifications furnished by Manufacturer?         Yes           No           Copy Attached          Yes             No

Plan drawings, picture, or sketch furnished by Mfg.?       Yes           No           Copy Attached          Yes             No

Unit Cost-Material only                                  Approximate Cost-Completed, in place

Are instructions or directions for installation, application, or use, available?        Yes                        No

Copy attached?      Yes               No              Will demonstration be provided?              Yes                  No

Are educational courses or videos available?       Yes           No            Royalty Cost        $

Is Product New on the Market?         Yes             No              (if yes) It was in (year)

Background Description of Company and its Product.



In what country is product produced:

Patented?     Yes         No        Applied for?   Yes           No         Date                  Proprietary?     Yes            No

Are quantities limited?     Yes        No          Will free sample be furnished upon request?               Yes             No

Has another office of the NC Department of Transportation been contacted?                              Yes              No

Which office?                                                    Contact Person




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                     NEW PRODUCT EVALUATION APPLICATION FORM
                                        (FILL ALL LINES or MARK N/A)


IV.      EVALUATION or TESTING INFORMATION

Does product meet standard specifications for testing by any organization as listed in section 101-2 of the NCDOT
Standard Specification for Roads & Structures?         Yes            No              If so, list AASHTO, ASTM
and/or Federal spec. number(s)

Is product used by Highway Authorities or other Transportation Agencies in other states?   Yes          No

            Name of Agency                 Years in Use             Name & Phone Number of Contact Person




                                       (Attach additional sheets if necessary)


Testing done by (agency, Independent Lab., etc.)

Evaluation status (pending, etc.)


Description of Lab Test Procedure

Description of Lab Test Results

Description of Field Test Procedure

Description of Field Test Results

Environmental Considerations


                                       (Attach additional sheets if necessary)


Person Furnishing Information                                        Title

I certify that the above information is correct
                                                                    Phone Number

Please attach: applicable trade literature, test results, Material Safety Data Sheets (MSDS’s),
specifications, instructions, guarantees, etc.




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                   NEW PRODUCT EVALUATION APPLICATION FORM
                                     (FILL ALL LINES or MARK N/A)


Please send FIVE (5) copies each of this completed form; specifications, sales literature, pamphlets,
booklets, binders, etc.,
TO:

(Items to be mailed should be sent to:)                  (Large Packages should be shipped to:)

Mr. Dale Frantz, New Products Coordinator                New Products Evaluation Coordinator
New Products Evaluation Committee                        New Products Evaluation Committee
N. C. Department of Transportation                       N. C. Department of Transportation
Design Services Unit                                     Century Center Complex, Entrance B-2
1591 Mail Service Center                                 1020 Birch Ridge Drive
Raleigh, NC 27699-1591                                   Raleigh, NC 27610




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