Authorized Field Test Site Application Form

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Date*
MM slash DD slash YYYY
Applicable Certification Program(s):*
- Authorized Field Test Site - Connected Vehicles (V2V and its applications)
- Authorized Field Test Site - Connected Vehicles (V2I and its applications)
- Authorized Field Test Site - Open Road Tolling (Overhead Gantry)
- Authorized Field Test Site - Plaza Tolling
Company:*
Company Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Field Test Site Name:
Field Test Site Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Point of Contact Name:*
Title:*
Direct Office or Mobile Phone:*
Point of Contact Email*
Field Test Site Authorization Fee*
Price:
Total
$0.00
Payment Option*
- Invoice Me
- Credit Card Payment
Billing Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(If different from above)
Credit Card*
Card Details
Cardholder Name