APPENDIX B TO PART 595--REQUEST FORM

U. S. DEPARTMENT OF TRANSPORTATION
NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION

REQUEST FOR AIR BAG ON-OFF SWITCH

OMB. No. 2127-0588
Expiration Date: 11/30/00

Vehicle Owner or Lessee Instructions:
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.

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)

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.

(At least one box must be checked.)

	Medical condition. The driver has a medical condition which, according to his or her physician: causes the driver air bag to pose a special risk for the driver; and makes the potential harm from the driver air bag in a crash greater than the potential harm from turning off the air bag and allowing the driver, even if belted, to hit the steering wheel or windshield in a crash.
	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.

(At least one box must be checked.)

	Infant. An infant (less than 1 year old) must ride in the front seat because: my vehicle has no rear seat; my vehicle has a rear seat too small to accommodate a rear-facing infant seat; or the infant has a medical condition which, according to the infant's physician, makes it necessary for the infant to ride in the front seat so that the driver can constantly monitor the child's condition.
	Child age 1 to 12. A child age 1 to 12 must ride in the front seat because: my vehicle has no rear seat; although children ages 1 to 12 ride in the rear seat(s) whenever possible, children ages 1 to 12 sometimes must ride in the front because no space is available in the rear seat(s) of my vehicle; or the child has a medical condition which, according to the child's physician, makes it necessary for the child to ride in the front seat so that the driver can constantly monitor the child's condition.
	Medical condition. A passenger has a medical condition which, according to his or her physician: causes the passenger air bag to pose a special risk for the passenger; and makes the potential harm from the passenger air bag in a crash greater than the potential harm from turning off the air bag and allowing the passenger, even if belted, to hit the dashboard or windshield in a crash.

Part E. I make this request based on following certification and understandings:

(Check each box below after reading carefully.)
	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.

Date	Signature of owner/lessee

Additional instructions and information for vehicle owners and lessees: An owner or lessee of multiple vehicles (e.g., a fleet owner) who wants an on-off switch for the same air bag (e.g., just the passenger air bag) in more than one vehicle and for the same reason does not need to submit a separate form for each vehicle. Instead, the owner or lessee may list the make, model, model year, and vehicle identification number for each of those vehicles and attach the list to a copy of this form. Each page of the list must be signed and dated by the owner or lessee. A list may also be attached to a single copy of this form if the owner or lessee wishes to request authorization for on-off switches for both air bags in multiple vehicles.

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.