ATTACHMENT 1

Application Form

This document provides the Washington State Department of Transportation (WSDOT) with basic information about the Applicant and its subcontractors and partners. Each Applicant must complete, sign and include this attachment in its Application.

Applicant’s Legal Name / Federal ID Number
-
Proposed Term (funding is available from July 1, 2017 through June 30, 2019)
Start Date / End Date
/ / /
Funding
Amount of Funds Requested / $
Match Funding / $ / Source of Match: / Cash In-Kind
Title of Project
Project Location
I-5
I-90
US 2
US 101
I-82/US 395
US 12
Other: Please List: ______
Project Description (brief paragraph, see instructions in Application Manual)
Applicant’s Project Manager (serves as point of contact for all communications)
Name:
Address:
City, State, Zip:
Phone:
E-Mail:
Applicant Is a
Non-Profit Organization
Government Entity (ie. City, county, federal or state agency, air district, transit system, tribe, university)
Private-For Profit Company—STOP—private companies are not eligible applicants for this opportunity.
Project Partners and Subcontractors? / No / Yes
Insert Subcontractor Legal Name
Insert Subcontractor Legal Name
Insert Subcontractor Legal Name
Insert Subcontractor Legal Name
Insert Subcontractor Legal Name
Insert Subcontractor Legal Name
Insert Subcontractor Legal Name
Insert Subcontractor Legal Name
Insert Subcontractor Legal Name
Insert Subcontractor Legal Name
Certifications:
I hereby authorize the Washington State Department of Transportation (WSDOT) to make any inquiries necessary to verify the information I have presented in my Application.
I hereby certify that this application does not contain any confidential or proprietary information.
I hereby certify to the best of my knowledge and belief that I have read, understand, and do hereby accept the terms and conditions contained in this package, including the provisions of the Agreement Terms and Conditions and, further, I am willing to enter into an agreement with WSDOT to conduct the proposed project according to the terms and conditions without negotiation.
I hereby certify to the best of my knowledge that the information contained in this Application is correct and complete.
Signature of Authorized Representative / Date:

Attachment 1 Application Form Page 1 of 2 EV Infrastructure Pilot Grant Application