U.S. Department of
Transportation
Office of the Secretary
of Transportation
Small Business Innovation Research
2004 Program Solicitation
DTRS57-04-R-SBIR
Proposal Cover Sheet (Appendix A)
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This form is a SAMPLE ONLY. For a working copy of the Proposal Cover Sheet, please download the solicitation.
Project Title _________________________________________________
Research Topic No. ______ Research Topic Title ___________________
Submitted by: Name __________________________________________
Address _________________________________________
City ________________ State ___________ Zip + ________
Amount Requested (Phase I) $ ___________ Proposed Duration _________
(May be up to $100,000 unless otherwise indicated) (in months)(Not to exceed six months)
The above concern certifies it is a small business firm and meets the definition stated in Section II.B; and that it meets the eligibility requirement in Section I.C.
Yes_______ No_______
The above concern certifies it _____does_____does not qualify as a minority and disadvantaged small business as defined in Section II.C. (For statistical purposes only.)
Yes_______ No_______
The above concern certifies it_____does_____does not qualify as a women-owned small business as defined in Section II.D. (For statistical purposes only.)
Yes_______ No_______
This firm and/or Principal Investigator has submitted proposals containing a significant amount of essentially equivalent work under other federal program solicitations, or has received other federal awards containing a significant amount of essentially equivalent work. (If yes, identify proposals in the Section III. D.10. "Similar Proposals or Awards".)
Yes_______ No_______
Will you permit the Government to disclose the title and technical abstract of your proposed project, plus the name, address, and telephone number of the Corporate Official and Principal Investigator of your firm, if your proposal does not result in an award, to any party that may be interested in contacting you for further information?
Yes_______ No_______
Do you qualify as a HUBZone-owned and meet the definition as stated in this solicitation? (Note this item is for statistical purposes only)
Yes_______ No_______
Principal Investigator Corporate/Business Official
Name__________________________ Name__________________________
Title____________________________ Title____________________________
Signature_______________Date_____ Signature_______________Date_____
Telephone No.____________________ Telephone No.____________________
PROPRIETARY NOTICE (IF APPLICABLE, SEE SECTION V. D.1)
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