TEMPLATE FOR

DOT EPLS Submission

OA Check appropriate agency:

     FAA________    FHWA_______   FMCSA ________    FRA_______   FTA______ 

    MARAD_____   NHTSA_______   OST_____    PHMSA________    RITA_______

For each EPLS Submission request, please complete the following information:

Name:

Address:

DUNS#:

Cause and Treatment Code:  (See http://epls.gov/)

Action Date:

Term Date

Please send this form electronically to:  Ellen.Shields@dot.gov.