Listee notification

Document Name:
Revision:
OMB Number:

NIJ CTP Listee Notification
07 Dec 2015
1121-0321

Approval Date:
Implementation Date:
Expires:

dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy

National Institute of Justice Compliance Testing Program
Multiple Listee Notification
In accordance with the Paperwork Reduction Act of 1995, no person is required to respond to a
collection of information unless it displays a valid OMB control number. The OMB number for
this collection is 1121-0321. Public reporting burden for this collection of information is
estimated to average 20 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the information.
This information is being requested pursuant to 6 U.S.C. 162(b)(4) and 6 U.S.C. 162(b)(6)(B).
The disclosure is voluntary. The information provided on this form will be used by the National
Institute of Justice to administer a conformity assessment program for products used by criminal
justice practitioners. This information and the associated products are voluntarily submitted
under the Compliance Testing Program.
PRIVACY ACT NOTICE: The information provided in this document is not considered
Confidential Commercial Information and may be released without limitations or restrictions.

This NIJ CTP Authorized Representative Notification is dated when signed by the
Applicant Signatory, and is between the Applicant and the Conformity Assessment Body
(“CAB”), which consists of both NIJ and the recipient of the Cooperative Agreement
Number 2014-IJ-CX-K004 issued by the Office of Justice Programs, NIJ.
The CAB implements the functions of the NIJ CTP, a program funded by NIJ, which in
turn is part of the U.S. Department of Justice (DOJ), Office of Justice Programs (OJP).
NIJ monitors and directs the administration of the NIJ CTP.
This agreement shall supersede all previous National Institute of Justice Compliance
Testing Program Listee Notifications for this model between the Applicant and the CAB.
Test ID:
Model Designation:
Date of Notification:

Please provide business headquarters information below.
Applicant Name:
Applicant Address:

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Document Name:
Revision:
OMB Number:

NIJ CTP Listee Notification
07 Dec 2015
1121-0321

Telephone:

Page 2 of 5

Approval Date:
Implementation Date:
Expires:

dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy

Document Name:
Revision:
OMB Number:

NIJ CTP Listee Notification
07 Dec 2015
1121-0321

Approval Date:
Implementation Date:
Expires:

dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy

Test ID:
Model Designation:

The Applicant hereby expressly acknowledges and agrees as follows:
Although it is not required that the Applicant has ownership of all brands or trademarks
identified here, the Applicant warrants that it has permission from the owner (Listee) to
engage in brand labeling of the product model identified above.
The NIJ CTP maintains a Compliant Products List (CPL) identifying models compliant
with program requirements. Product listing includes model designation and
Listee/Brand.
Other than the Listee information provided here and included on the label, no other
changes are permitted by this agreement.
Use of this form to identify multiple Listee status does not authorize additional or
alternative manufacturing locations.
The NIJ CTP shall hold the applicant responsible for actions they or the Multiple
Listee(s) may take in regards to this model. Failure of the Applicant or additional
Listee(s) to abide by the requirements of the NIJ CTP could have a negative impact on
the Applicant’s continued participation in the NIJ CTP, up to and including the removal
of all Applicant models from the CPL under any brand or trademark.
Final labeling shall be both controlled by and the responsibility of the Applicant.
Listee # 1:
Company:
Name
Address

Point of Contact:
Name
Title
Phone
E-mail
Trade Name/Brand
Page 3 of 5

Document Name:
Revision:
OMB Number:

NIJ CTP Listee Notification
07 Dec 2015
1121-0321

Test ID:
Model Designation:

Listee # 2:
Company:
Name
Address

Point of Contact:
Name
Title
Phone
E-mail
Trade Name/Brand

Listee # 3:
Company:
Name
Address

Point of Contact:
Name
Title
Phone
E-mail
Trade Name/Brand

Page 4 of 5

Approval Date:
Implementation Date:
Expires:

dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy

Document Name:
Revision:
OMB Number:

NIJ CTP Listee Notification
07 Dec 2015
1121-0321

Approval Date:
Implementation Date:
Expires:

dd Mmm yyyy
dd Mmm yyyy
dd Mmm yyyy

Test ID:
Model Designation:

Applicant Signatory
(an officer or representative of the Applicant who has the authority to bind it)
(Name/Title):
Telephone Number:
E-mail:
□
additional pages have been attached (each page initialed and dated) to indicate
additional manufacturing locations.
The Applicant agrees to the terms of this agreement and warrants that it has made no
alterations to its text. The undersigned represents and warrants that he/she is
authorized to execute this agreement on behalf of the Applicant and the Multiple Listees
referenced here.

Applicant Signatory

Date

NLECTC-National Representative Acknowledgement:

Signature

Date

Name (Please print/type)

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