	    
	 Control No. ______________	
				
                                TEST AGREEMENT
                                       
	Your vehicle is being loaned to Jacobs, a contractor for the U.S. Environmental Protection Agency, for use in a government-sponsored program for cleaner air.  This executed Agreement is your assurance of full protection against any loss sustained by accident or damage to the vehicle while in the possession of Jacobs, a contractor to the U. S. Environmental Protection Agency, or its designated representatives.

	Jacobs agrees to be fully responsible for any and all damage to the vehicle occurring while the vehicle is in its possession.  Possession is hereby defined as care, control, custody, operation, inspection, or storage between the time the vehicle is received from the owner by Jacobs, and the time the vehicle is returned to the owner.

	Jacobs agrees to exercise extreme care in the use of the vehicle and agrees to return the vehicle to the owner in as good exterior, interior, and operating condition, except for normal wear and tear, as when the vehicle was received by Jacobs.

	Jacobs agrees to indemnify and hold harmless the vehicle owner of any repairs, damage, loss, or liability sustained by the vehicle owner by reason of accident or damage to the vehicle while in the possession of Jacobs, or its representatives.

	Jacobs agrees to provide primary automobile insurance on the vehicle while in its possession.

	Jacobs reserves the right to perform any repairs and maintenance upon the vehicle, at its sole discretion, provided all such repairs and maintenance are performed according to the manufacturer's specifications.


	I, ______________________________________________________, agree to loan my vehicle 

described as a  _________ (Year)  _____________________________ (Model),  

VIN______________________________________________ to Jacobs, for a period of 

approximately                   weeks for a series of tests.  I understand that I may refuse to loan my 

vehicle to Jacobs at any time and that I am under no obligation whatsoever.
      

            Agreed to this ______________ day of ____________________, 20____.
PARTICIPANT:

____________________________________					_______________
		Signature								Date

JACOBS REPRESENTATIVE:

_____________________________________					________________

		Signature								Date



                                                  
                                                                               

                             Privacy Act Statement

Title 42, United States Code, Section 7451, Compliance by vehicles and engines in actual use, authorizes the collection of this information.  The primary use is to provide an instrument by which individuals may indicate interest in and eligibility for participating in EPA's Light-Duty In-Use Testing Program.  Additional disclosures of this information may be made pursuant to published routine uses, including to appropriate agencies for law enforcement purposes and to contractors working for EPA who have a need to know in the course of that work.
Providing the requested information is voluntary, but failing to do so will result in EPA's inability to approve your participation in the Light-Duty In-Use Testing Program.







This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0086). Responses to this collection of information are voluntary (42 USC 7541.) An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to range from 1 to 60 minutes per response, with an average of 30 minutes per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.




