Application for Determination That a Motor Vehicle Is
Eligible for Show or Display
The vehicle is of technological significance.
The vehicle is of historical significance.
The vehicle is of exceptional significance (if total production exceeded 500 units).
4. DOCUMENTS ATTACHED
Photographs.
Production Verification.
Documentation to support historical or technological significance.
1. APPLICANT (Owner):
Name: ____________________________ E-Mail Address: _______________________
Street Address: ___________________________________________________________
City: ________________________ State: ___________ ZIP: ______________________
Tel: (________) _____________________ Fax: (________) _______________________
2. VEHICLE IDENTIFICATION:
Year: _____________________ Chassis Number: _______________________
Make:_____________________________ Model: _____________________________
3. BASIS FOR APPLICATION:
VIN or
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 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.
