Application For Determination That A Motor Vehicle Form - Nhtsa

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OMB No. 2127-0002

Exp. 04-30-2017

Application for Determination to Import a Motor Vehicle

Is Eligible for Show or Display

APPLICANT (Owner):

Name: ____________________________ E-Mail Address: _______________________

Street Address: ___________________________________________________________

City: ________________________ State: ___________ ZIP: ______________________

Tel: (________) _____________________ Fax: (________) _______________________

VEHICLE IDENTIFICATION:

Years: _____________________

Make: _____________________________ Model: _____________________________

BASIS FOR APPLICATION:



The vehicle is of technological significance.



The vehicle is of historical significance.



The vehicle is of exceptional significance (if total production exceeded 500 units)

DOCUMENTS ATTACHED



Photographs



Production Verification.



Documentation to support historical or technological significance

PAPERWORK REDUCTION ACT STATEMENT: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply

with, a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number

for this information collection is 2127-0002. The information collected on this form is necessary to obtain a decision from NHTSA that a motor vehicle that does not comply with all applicable Federal

motor vehicle safety standards possesses sufficient historical or technological significance to be imported for purposes of show or display. The information is used to verify that a vehicle is eligible to be

imported on this basis. We estimate that it will take approximately 10 hours minutes to complete the form, including the gathering, preparation, and assembly of all necessary attachments. The information

collected is necessary to obtain a benefit under 49 U.S.C. 30114 and 49 CFR 591.5(j)(1)(iii), 591.6(f)(2) and 591.7(d). Send comments regarding this burden estimate or any other aspect of this collection

of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Room W45-205,

Washington, DC, 20590.