Operations Academy Nomination Form 2020 Due Date: June 1, 2020 Name* First Last Name to be Printed on Name Tag*Organization*Title*Work Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Phone*Cell Phone*Email* Type of Organization* Federal State Local (City, County) MPO Private Sector Other (please specify) Other Type of OrganizationSupervisor Information:Supervisor Name*Supervisor Phone*Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Email* General InformationResponsibilities* Operations planning (regional cooperation, funding sources) Social, environmental and institutional issues (including public/private partnerships) Freeway operations Corridor management Surface street operations (including signal operations) Project management (including return on investment, performance measures, contracting) Traffic engineering Traffic control devices TSM&O and/or ITS Systems engineering (including standards) Other (please specify): Other ResponsibilitiesBriefly describe your current responsibilities*(Your description may be as long as necessary.Why do you want to participate in this program?*(Your description may be as long as necessary.What do you expect to get out of the program?*(Your description may be as long as necessary.Emergency Contact InformationContact Name*Phone Number*Relationship to You*Nominating Organization Information (Must be a Federal, state or local transportation agency)Organization*Contact Name*Contact Phone*Contact Email* Program Dates and Fees Please note the dates, fees and select polo shirt size. Program Dates: October 19-30, 2020 These dates include the weekend. Program will begin at 5:00 PM on Monday, Oct 19, 2020 Fees: Program Fees (required): $3,909 You will receive an Operations Academy polo shirt. Please tell us your size:* Small Medium Large X-Large 2X-Large 3X-Large Payment OptionsHow would you like to pay for the program?*I-95 Corridor Coalition Scholarship*Purchase OrderCheck (made payable to the University of Maryland)Credit Card (will need to call with number) *I-95 Corridor Coalition Scholarship Selection Criteria: (click here) Application Quality Potential to enhance TSM&O implementation Active involvement in Coalition activities Contribution to creating a multi-disciplinary academy Equitable distribution across Coalition members All program fees will be due seven weeks after notification of acceptance into the program (August 3, 2020). Any cancellation must be received 60 days prior to the start of the program (August 20, 2020) to receive a refund of all fees, less a non-refundable amount of $500. No refund of any fees will be granted if cancellation occurs with less than 60 days prior to the start of the program. If you are paying by check, mail your check to: Lisa Baldwin Center for Advanced Transportation Technology 5000 College Ave, Suite 2206 Technology Ventures Building University of Maryland College Park, MD 20742-6602 October 2020 Operations Academy Nomination Form Due June 1, 2020