U. S. DEPARTMENT OF TRANSPORTATION |
OMB. No. 2127-0588 Expiration Date: 11/30/00 |
REQUEST FOR AIR BAG ON-OFF SWITCH |
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Read the National Highway Traffic Safety Administration (NHTSA) information brochure, "Air Bags & On-Off Switches, Information for an Informed Decision." If you want authorization for an on-off switch for your driver air bag, passenger air bag, or both, fill out Parts A, B, E and F completely, fill out Parts C and D as appropriate, and send this form to:
- Please print.
- Please note: Incomplete forms will be returned to the owner or lessee.
- If you need a copy of the brochure or have any questions about how to fill out this form, call the NHTSA Hotline at 1-800-424-9393.
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National Highway Traffic Safety Administration
Attention: Air Bag Switch Request Forms
400 Seventh Street, S. W.
Washington, D.C. 20590-1000
Part A. Name and address | ||
First |
Middle | Last |
Street address(Residence) |
City | State | Zip Code |
Part B. I own or lease the following vehicle: (Owners of multiple vehicles should consult the additional instructions at the end of this form): | ||||||||||||||||||
Make |
Vehicle Identification Number (located on driver's side of dashboard near windshield and on certification label on driver's door frame) |
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Model | Model year |
Part C. Switch for Driver Air Bag.
I request authorization for the installation of an on-off
switch for the driver air bag in my vehicle. I certify that I or
another driver of my vehicle meets the criteria for the risk group
checked below. |
|
Medical condition. The driver has a medical
condition which, according to his or her physician:
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Distance from driver air bag. Despite taking all reasonable steps to move back from the driver air bag, the driver is not able to maintain a 10-inch distance from the center of his or her breastbone to the center of the driver air bag cover. |
Part D. Switch for Passenger Air Bag.
I request authorization for the installation of an on-off
switch for the passenger air bag in my vehicle. I certify that I or
another passenger of my vehicle meets the criteria for the risk group
checked below. |
Infant. An infant (less than 1 year old) must ride
in the front seat because:
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Child age 1 to 12. A child age 1 to 12 must ride in
the front seat because:
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Medical condition. A passenger has a medical
condition which, according to his or her physician:
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Part E. I make this request based on following
certification and understandings: (Check each box below after reading carefully.) |
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Information brochure. I certify that I have read the NHTSA information brochure, "Air Bags & On-Off Switches, Information for an Informed Decision." I understand that air bags should be turned off only for people at risk and turned back on for people not at risk. | |
Loss of air bag protection. I understand that turning off an air bag may have serious safety consequences. When an air bag is off, even belted occupants may hit their head, neck or chest on the steering wheel, dashboard or windshield in a moderate to serious crash. That possibility may be increased in some newer vehicles with seat belts that are specially designed to work with the air bag. Those belts, which are designed to reduce the concentration of crash forces on any single part of the body, typically allow the occupant to move farther forward in a crash than older belts. Without the air bag to cushion this forward movement, the chance of the occupant hitting the vehicle interior is increased. | |
Waiver. I understand that motor vehicle dealers and repair businesses may require me to sign a waiver of liability before they install an on-off switch. |
Part F. Certification.
I certify to the U. S. Department of Transportation that the information, certifications and understandings given or indicated by me on this form are truthful, correct and complete to the best of my knowledge and belief. I recognize that the statements I have made on this form concern a matter within the jurisdiction of a department of the United States and that making a false, fictitious or fraudulent statement may render me subject to criminal prosecution under Title 18, United States Code, Section 1001. |
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Date |
Signature of owner/lessee |
Please note that 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. That number appears above.