Missouri Department of Transportation
Form NPE 09
(Rev. 01/2016)
New Product Evaluation Form for TR201720
Rejuvenators and Surface Sealing Products to Extend Asphalt Pavement Life
This MoDOT new product evaluation form shall be used to submit new products for MoDOT Research RFI TR201720 Rejuvenators and Surface Sealing Products to Extend Asphalt Pavement Life.
The Manufacturer/Supplier should indicate on the form which product submission category (or both) under which the product is intended to be evaluated. A form should be completed for each product.
For this project, the Manufacturer/Supplier must install the product or must be present for the installation.
UInstructions
Manufacturer/Supplier should submit two gallons of each product for testing.
Completed form (and applicable attachments)
should be submitted to: 31T
Mail product along with a copy of completed form to: Attn: Jeff Joens
MoDOT Construction & Materials
1617 Missouri Blvd.
P. O. Box 270
Jefferson City MO 65109
Missouri Department of Transportation
New Product Evaluation Form for TR201720 Rejuvenators and Surface Sealing
Products to Extend Asphalt Pavement Life
I. Product Identification
Product Name: ______________________________________________________________________________
Product Model Number: _______________________________________________________________________
Product Web Site: ____________________________________________________________________________
Product Submission Category (see RFI for more information):
☐ Mainline Pavement Application ☐ Longitudinal Construction Joints Application
II. Product’s Contact Information
Manufacturer, Source, or Other:
Manufacturer’s Company Name: ____________________________________________________________
Contact Person: __________________________________________________________________________
Address: __________________________ City: ___________________ State: _____ Zip: ________
Phone No.: _________________ Fax: ________________ Email: _____________________________
Vendor, Fabricator, Distributor, or Other:
Representative’s Company Name: ___________________________________________________________
Contact Person: __________________________________________________________________________
Address: __________________________ City: ___________________ State: _____ Zip: ________
Phone No.: _________________ Fax: ________________ Email: _____________________________
III. New Product Description
Product Description: _________________________________________________________________________
Primary Use: _______________________________________________________________________________
Secondary Use: _____________________________________________________________________________
Generic Material Composition: _________________________________________________________________
Does product contain Hazardous Materials? ☐ Yes ☐ No Identify %: _______
If “Yes,” describe: _____________________________________________________________________
Does product contain recycled materials? ☐ Yes ☐ No
If “Yes,” describe: _____________________________________________________________________
Availability: _________________________________ ☐ Seasonal ☐ Non-seasonal
Shelf Life: _________________________ Approximate delivery in days after receipt of order: ___________
Storage Requirements: _________________________________________________________________________
Are quantities limited? ☐ Yes ☐ No Describe: ___________________________________________
Estimated cost per unit at end of evaluation: __________ Estimated cost per unit installed: ______________
Is special equipment required to install product? ☐ Yes ☐ No
If Yes, please specify ______________________________________________________________
I certify that the information above is correct:
Name (print): _________________________________________________________________________
Date: ___________________________
Phone no.: _______________________
Email: __________________________