Date:

Product Name:

Manufacture’s Name:

Street Address:

City, State, Zip Code:

Contact Name:

Email Address:

Telephone Number:

Web Page Address:

I certify that the product listed above is of the same composition and design as currently approved by the Idaho Transportation Department Qualified Products List program. I also certify that the Manufacture’s contact information is as listed above.

Manufacturer’s Representative Signature: ___________________________________________

Name (printed):

Signature Date:

Please submit completed Certification and Idaho Transportation Department Product Review Application to: QPLAdmin@itd.idaho.gov for product re-certification.