Authorization to Deactivate an Air Bag

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I, ____________________________________________________, am (Vehicle Owner's Name)
the owner of the following vehicle:

(Make (e.g., Chevrolet))

(Model (e.g., Lumina))

(Model year)

(Vehicle Identification Number)


(State in which vehicle is registered)

(Registration #)

I authorize _______________________________________________
(Name of motor vehicle dealer or repair business)

(Address of dealer or repair business)

to modify the vehicle identified above in the following way:

In the appropriate box(es) below, initial which air bag or bags you want deactivated

Deactivate my driver air bag

Deactivate my passenger air bag

I make this authorization with the following acknowledgments and understandings:

Owner must initial each box below Owner acknowledgments and understandings

Information sheet. I acknowledge that the dealer or repair business identified above has given me a copy of an air bag information sheet prepared by the National Highway Traffic Safety Administration and that I have read the sheet.

Loss of protection. I understand that a deactivated air bag will not deploy and thus will not provide protection in the event of motor vehicle collision.

Attaching of labels. I understand that the dealer or repair business identified above is required by law to install labels on the sun visor and door jamb for each air bag that is deactivated pursuant to this authorization.

I understand that the labels are intended to alert present and future owners and users that one or both air bags are deactivated.

I will allow the dealer or repair business to attach the labels and ensure that they remain in place as long as the air bag(s) remain(s) deactivated.

Waiver of claims. I acknowledge that, by authorizing the deactivation of an air bag in my vehicle, I waive any claim or cause of action that I may have against the dealer or repair business because the air bag has been deactivated.

______________________________________________ ___________________
(Signature of vehicle owner) (Date)