PROJECT PREAPPLICATION DATA SHEET

WYOMING DEPARTMENT OF TRANSPORTATION AERONAUTICS DIVISION

5300 Bishop Blvd, Cheyenne, WY 82009-3340

http://www.dot.state.wy.us/home/aeronautics.default.html

Directions: Please complete a Project Preapplication Data Sheet for each new or revised project requested in first 6 years of WACIP.

Part 1: Applicant Information

Airport Name: Click here to enter airport name.	Date: Click here to enter today’s date.

Part 2: Project Information

Project Description*: Click here to enter the project description.	Requested Fiscal Year*:	Local Priority*: Click here.
* Project description, requested fiscal year and local priority must exactly match the information given on Proposed WACIP Summary.
Scope of Work (list all major work items): Click here to enter a detailed project description.
Project Purpose as Defined in 2014 Wyoming Priority Rating Model for Project Evaluation: (select one) Choose an item.	Project Component: (select all that apply)
Airside Primary R/W or T/W, Airfield Lighting
Airside Secondary R/W or T/W
Is this a new project? Choose an item.	Airside Apron, Structures, or Equipment
Airside Taxilane (other than Apron) or Landside
Other: (specify)
Justification (why this project is important and should be funded): Click here to enter justification for this funding request.
Would you like this project (or a phase of it) considered as “Shovel Ready”?** Choose an item.	If identified as a “Shovel Ready” project, what would be the earliest fiscal year the project could be started (not including separate design)?
** In order to qualify as “Shovel ready”, confirm that the project fits the following criteria: The sponsor has the ability to commit to the local portion of the match. The project could be prepared and ready to bid within 1-2 months after notice by the Division. If a phased project, the acceleration will not adversely affect follow-up phases.

Part 3: Proposed Project Cost Estimate

General Item:	Units	Quantity	Unit Cost	Total
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Consultant Fees (Engineering/Planning)
Total Estimated Project Cost (Rounded to the nearest dollar)
If this is not a new project, have cost estimates changed?*** Choose an item.
*** Please note, if you are only revising the cost estimate, you do NOT need to submit a whole new Preapplication.
Proposed % Split:	Federal:	State:	Local:
Does the proposed % split deviate from the standard WAC match (outlined in WAC Policy #11)?****
**** If yes and additional state funds are requested, a written deviation request explaining the reason for the alternate match percentage MUST accompany this form.

Part 4: Required Attachments

Use the following checklist to ensure that all required attachments are included in the preapplication packet for each project.

Project Sketch (if applicable) - Clearly designate the specific area of work involved
Detailed Cost Estimate (if available)
Percentage Match Deviation Request, if applicable. (Only applies to the first two years).

Part 5: Contact Designation

The Sponsor hereby designates the following as the contact for all questions regarding this project:
Name: Click here to enter contact’s name.	Title: Click here to enter contact’s title.
Address: Click here to enter contact’s address.	City, State, Zip: Click here to enter contact’s city, state and zip.
Phone: Click here to enter contact’s phone number.	Email: Click here to enter contact’s email address.

Part 6: Sponsor Certification

To the best of my knowledge and belief, all data in this preapplication are true, accurate and complete.
Sponsor Signature:	Date: Click here to enter a date.