Qualified Traffic Control Equipment Submission Form for
Sign Supports and Mounting Harware
Submission Instructions: Please submit one application per product. Catalogue cuts shall be included as
attachments. FHWA Federal-aid eligibility letters, if applicable shall be included with submittal and test results
from an independent test lab shall be submitted to ensure compliance. Other testing results or certifications
which may assist in evaluation may also be included. All equipment shall comply with the latest edition of
Section 840 - Sign Supports of the Standard Specifications
, including Supplemental and Interim editions. Upon
evaluation MassDOT Highway Division will contact you.
Part A. Applicant Information
Today's Date
Name
Company
Address
City, State ZIP
Phone
Email
Part B. Basic Product Information
Name or Model #
Description
Link to product cutsheet
Product Type
Square Post U-
Channel Post
Breakaway System Sign Mounting Bracket
Other:
Part C. Technical Product Information
Product Material(s)
Available Finishes
Dimensions
Please complete this section for Sign Supports and Breakaway Systems, only.
Test Level n/a TL-2 TL-3 TL-4 TL-5
Methodology NCHRP 350 MASH
FHWA Acceptance Letter(s):
FHWA Limits on Use
Application Revision: November 13, 2014 Sign Supports and Hardware Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 1 of 3
Technical Notes (if necessary):
Part D. Product Use
Has this product, or one similar, been previously submitted to MassDOT? Yes No
If Yes, please explain:
Is this a replacement product for one currently approved by MassDOT? Yes No
If Yes, please explain:
Is
this product currently in use in Massachusetts? Yes No
If Yes, please explain:
State DOTs that have
approved this product:
Is this product in commercial production? Yes No
If Yes, for how long?
If No, please explain:
Have there been any recalls on this product? Yes N
o
If Yes, please explain:
Recommended Routine Maintenance Program (if applicable):
Warranty Information:
Application Revision: November 13, 2014 Sign Supports and Hardware Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 2 of 3
Part E. Contact Information
Supplier/
Distributer
Contact Title
Company
Website
Address City, State ZIP
Email Phone
Manufacturer
Contact Title
Company
Website
Address City, State ZIP
Email Phone
Reference #1
Contact Title
Agency
Email Phone
Reference #2
Contact Title
Agency
Email Phone
(This space may be used to provide additional information)
Applications may be submitted to james.danila@dot.state.ma.us or by mail to:
Jim Danila, P.E., Assistant State Traffic Engineer
Traffic and Safety Engineering Section, MassDOT Highway Division
10 Park Plaza, Room 7210
Boston, MA 02116
Application Revision: November 13, 2014 Sign Supports and Hardware Application
Qualified Traffic Control Equipment: http://goo.gl/OS7o5N Page 3 of 3