ALABAMA DEPARTMENT OF TRANSPORTATION PRODUCT EVALUATION BOARD

New Product Evaluation Application Form

One product (model) per submittal form. Instructions for completion on page 4 Please contact the Product Evaluation Engineer aldotpeb@dot.state.al.us (334) 353-6940, if this product is covered by an ALDOT specification(s) and is not covered under an approved products list or for general questions about this form. NOTE: You must have legal right to submit the product for evaluation.

Product Information

Trade Name

Model Number

Manufacturer Vendor (If other than manufacturer, List the local Distributor)

Contact Contact

Company Company

Address Address

City City

State Zip Phone State Zip Phone

Applying for Qualified Product List(s) Designation

Has this product previously been submitted to ALDOT for evaluation?

If yes, provide previous application ID #

Product Description

Recommended Uses—Primary

Recommended Uses—Alternate

Outstanding Features or Advantages

PEB # _______ Official Use Only

YES NO

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Material Composition (attach laboratory report and Material Safety Data Sheet)

Alternate or comparable to what existing material or product(s)

Patented? attach copy of patent Patent Number(s)

Proprietary Item Country of Origin

If the Product is selected for use on a project, then the Manufacturer will be required to furnish proper documentation with the shipment, confirming your company’s compliance with Buy America Act (23CFR 635.410) and the current ALDOT standard specification, Section 106.

SPECIFICATION INFORMATION

AGENCY/ORGANIZATION APPLICABLE?

SPECIFICATION(S) DETAIL YES NO

ALDOT Standard Specifications

ALDOT Special Provisions

AASHTO

ASTM

MUTCD

Federal Inspection/Opinion

Other Specifications (List)

TESTING INFORMATION

AGENCY/ORGANIZATION APPLICABLE?

TEST DATA/RESULTS YES NO

NTPEP

Independent Lab Test (List)

Other Tests (List)

COST, AVAILABILITY and WARRANTY

Estimated cost of materials per unit? Delivery at site within days after receipt of order

YES NO If yes, explain

Is product seasonal

Are quantities limited

Will free sample(s) be provided for laboratory or field tests

Will free installation of the material in the field be provided

Will onsite supervision of first installation in the field be provided

Will special equipment be required to install the product

Is the Material/Product guaranteed Conditions

YES NO

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OTHER DOT(s) AGENCY CONSIDERATIONS – list products approved by other highway authorities or other agencies Attach additional sheets if needed

Agency/Organization Contact Name & Number Approval List(s)

OTHER DOT(s) AGENCY CONSIDERATIONS – list products under evaluation for approval by other highway authorities / agencies Attach additional sheets if needed

Agency/Organization Contact Name & Number Consideration List(s)

REQUIRED DOCUMENTATION The following applicable information and materials are available and are required to accompany this form in order to substantiate, verify or clarify its content

Specifications Attached Not Applicable

Drawings, Sketches, Pictures

Installation Instructions

Material Safety Data Sheets

Product/Material Literature

Test Data/Laboratory Reports

Certifications

Warranty

The manufacturer/distributor is hereby notified that the ALDOT, Product Evaluation Board reserves the right to release or distribute any of the information included in this form as well as any recommendations the Board may make concerning the product. ALDOT will only consider any products for evaluation or testing when all criteria are received to the ALDOT Bureau of Research and Development. The required application fee is $50 per product from and must accompany this form. All other associated testing fees are provided in the ALDOT 355-88. A check or money order must be made payable to the Alabama Department of Transportation.

Printed Name of Submitter

Title Contact Number

Company Name

Signature Date

Kidada Dixon, P.E. – Assistant Research and Development Engineer Research and Development Bureau Alabama Department of Transportation 3700 Fairground Road Montgomery, AL 36110

ALABAMA DEPARTMENT OF TRANSPORTATION PRODUCT EVALUATION PROGRAM 

APPLICATION INSTRUCTIONS & GENERAL INFORMATION  

Product List/Categories: There are over 50 products lists available on the ALDOT Approved List of Qualified Materials, Sources and Devices.  Please review ALDOT’s List of Qualified Materials, Sources and Devices for similar products and determine the category that best applies to your product.  If more than one category applies, please list the additional categories to be considered.    Each  product  list  has  requirements  that  are  outlined  in  the  respective  Procedure  for  Evaluation  and Maintenance.  To  review  this  document  visit www.dot.state.al.us/mtweb/Testing/MSDSAR/QMSD.html  to ensure that all criteria is met for a complete product package submittal.    Associated Testing Fees*    Standard Testing Fees (ALDOT 355‐88)    Traffic Control Device Fees        http://www.dot.state.al.us/mtweb/Testing/MSDSAR/msdsar_index.html *All  fees  must  be  paid  by  check  or  money  order  and made  payable  to  the  ‘Alabama  Department  of Transportation’.  Product Name/Model:   Provide the name and model number/series of the product.  Please complete one application per product.  The name and model number should be the same identification used in the product package literature/marketing material.   Assigned Tracking  ID: Tracking  identification numbers are assigned to each product when  the package  is reviewed and considered complete for processing.  If this product has been reviewed previously by ALDOT and has been modified/revised/removed, then please provide that assigned PEB number.    Product Description: Please provide a general description of the product. It should be brief, but match the description in the package literature/marketing material.  Primary Use: Briefly describe how the product is used.   Advantages: Briefly describe how the product would be beneficial to the ALDOT for usage.  Cost, Availability, and Warranty: Please provide an estimated cost of the product’s cost. The estimate would not be an official quote.  ALDOT  Standard  Specifications:  If  the  product  submitted  meets  an  ALDOT  specification(s),  then  please specify the section of the Standard Specifications.  ALDOT Standard Specification can be found at  http://www.dot.state.al.us/conweb/specifications.html   ALDOT Special Provision: If the product submitted meets an ALDOT Special Provision, then please specify the Special Provision number.  ALDOT Special Provisions can be found at http://www.dot.state.al.us/conweb/specifications.html   Signature:  All forms must be hand signed in order to be considered complete.    The new product evaluation procedure flow chart is available at: http://www.dot.state.al.us/rdweb/ProductEvaluation.html   

If there are any questions, please contact the Product Evaluation Engineer via email at ALDOTPEB@dot.state.al.us or by phone at (334) 353‐6940.