Form Av-2 - Autonomous Vehicle Technology Demonstration/testing Addendum

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AUTONOMOUS VEHICLE TECHNOLOGY DEMONSTRATION/TESTING ADDENDUM
The entity named herein agrees to comply with the requirements of the New York State Police as specified in this addendum.
Direct supervision by the New York State Police shall be determined for purposes of the demonstration or test by the Superintendent
in consultation with the entity named herein. The supervising member of the New York State Police is authorized to terminate such
demonstration/testing if that member believes continued operation is a threat to safety. If the demonstration/testing jeopardizes
safety, the entity applying to demonstrate/test shall assume any and all liability associated.
PART I: TEST VEHICLE OPERATORS
Every test vehicle operator shall be adequately trained in the safe operation of the test vehicle to ensure both legal and safe operation.
Each test vehicle operator must be listed below:
License
Operator Name
Date of Birth
Jurisdiction
License Number
Expiration Date
PART II: TEST ROUTE SPECIFICATIONS
The entity shall include in this addendum the specific routing information including date, time, origin, destination, the sequence of
roads on which it intends to travel, and total routing distance in miles to the nearest 1/10 mile. The route shall NOT include construction
zones or school zones.
The entity named herein shall reimburse the New York State Police for direct supervision of each demonstration/test according to the
following rate schedule:
NYSP Autonomous Vehicle Test Supervision Rate Calculations
Regular hourly rate
Overtime hourly rate
Mileage cost
$ 92.73
$ 131.67
53.5 ¢ per mile
SIGNATURE/CERTIFICATION
I certify that I am duly authorized to submit this addendum on behalf of, and with the power to bind, the entity named herein, and
all information I have provided in connection with this addendum is true and complete to the best of my knowledge. The entity
named herein agrees to comply with all terms and conditions set forth herein.
WARNING:
ntentionally making a false statement or providing false or misleading information in connection with this application
is a criminal offense that may subject you to criminal prosecution under the Law.
Entity Name
(Please Print):
ç
BY, (Sign)
Print Name:
Title:
Date:
/
/
(mm/dd/yyyy):
APPROVAL
Approval Date: ______/______/__________
George P. Beach II
Superintendent
New  York State Police
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AV-2 (5/17)

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