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DOT Program Solicitation for
Small Business Innovation Research

Proposal Cover Sheet (Appendix A)

Previous Section | Program Contents | Next Section

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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)

1. 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_______

2. The above concern certifies it _____does_____does not qualify as a socially or economically disadvantaged small business as defined in Section II.C. (For statistical purposes only.)

3. 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.)

4. 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_______

5. 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/Business 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_______

6. Do you qualify as a HUBZone-owned and meet the definition as stated in this Section II. G (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)