Office of Traffic Safety
Minnesota Child Passenger Safety Program
Car Seat Distribution Application
Contact Information
Agency
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Agency name is required
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Contact Name
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Contact name is required
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E-mail Address
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Email address is required
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Phone Number
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Fax Number
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National CPS Certification Technician / Instructor
You must have a Nationally Certified Child Passenger Safety Technician / Instructor at your agency in order to receive the seats; failure to have a current, Minnesota, child passenger safety technician, will be a denial of the grant application.
Name(s) CPS trained staff responsible for car seat distribution
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Name required
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CPST Name(s) & Safe Kids Worldwide Certification Number
*
Certification Number required
Shipping Address (where car seats should be shipped)
Street Address
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Address is required
Address Line 2
( Apt, Suite, Unit, etc. )
County
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County is required
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City
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City is required
State
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Zip Code
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Required field
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Child Safety Seat Requests
Please indicate the number of seats you can reasonably distribute in one year. Most awards will not exceed 10 total car seats.
Convertible seat with 5-pt. harness (order in multiples of 2)
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Combination seat with 5-pt. harness (order in multiples of 2)
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Booster, high back (order in multiples of 2)
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Booster, no-back (order in multiples of 4)
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This agency accepts the
requirements
of the Minnesota Child Restraint and Education Account program to distribute seats.
Accept Terms
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