OMB No. 2127-0040
Expiration Date: 07/31/2009

Paperwork Reduction Act Burden 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 2127-0040.  Public reporting for this collection of information is estimated to be approximately 30 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information.  All responses to this collection of information are mandatory.  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, 400 7th St, SW Washington, DC, 20590, Washington, D.C. 20590.

APPENDIX: SUGGESTED DESIGNATION
OF AGENT FOR SERVICE OF PROCESS
UNDER 49 U.S.C. § 30164 and 49 C.F.R. Part 551, Subpart D

PART A: DESIGNATION BY FOREIGN MANUFACTURER

Pursuant to 49 U.S.C. § 30164 and 49 C.F.R. Part 551, Subpart D, the Foreign Manufacturer listed below hereby designates the following Agent on whom service of all administrative and judicial processes and notices may be made.  This designation is for service of process only and for no other purpose.  It shall remain in effect until it is withdrawn or another Agent is designated in accordance with the requirements of 49 U.S.C. § 30164 and 49 C.F.R. Part 551, Subpart D.

The Manufacturer identified below hereby certifies:

  1. This designation is in valid form and binding on the Manufacturer under the laws, corporate bylaws or other requirements governing the making of designations at the place and time where it is made.
  2. The full legal name, principal place of business and mailing address of the Manufacturer are:









  3. The Manufacturer’s products will be sold under the following trade or brand names, marks, logos or other designations of origin (List all names, marks, logos or designations):
  4. The full legal name, principal place of business, mailing address and telephone number of the Agent are:





        (two letter abbreviation)



By:

Signature of Manufacturer’s Authorized Representative
Month / Day / Year

Printed Name:
Title:

PART B:  ACCEPTANCE BY AGENT

The undersigned hereby accepts appointment as Agent solely for the purpose of service of process on the Manufacturer under 49 U.S.C. § 30164 and 49 C.F.R. Part 551, Subpart D.  I understand that this appointment shall remain in effect until withdrawn or replaced by the Manufacturer in accordance with the requirements of 49 U.S.C. § 30164 and 49 C.F.R. Part 551, Subpart D. I understand also that I may not assign performance of my functions under this Designation to another person.

By:

Signature of Agent
Month / Day / Year

(Date of acceptance must be on or after date of designation)

Printed Name:
Title:

TO AVOID DELAYS, LEAVE NO SPACES BLANK; DO NOT SEND VIA FACSIMILE OR EMAIL

Mail original documents with ink signatures only to: U.S. Department of Transportation, NHTSA Correspondence Unit, 1200 New Jersey Avenue, SE, Room W41-306, Washington, D.C. 20590


After you submit your designation information online, a database will save the information and create an Adobe PDF of a designation form that you must print, sign, and mail to the above address.

TO COMPLY WITH PART 551, SUBPART D, YOU MUST SIGN AND MAIL TO NHTSA AN ORIGINAL PRINTOUT OF THE ADOBE PDF WITH INK SIGNATURES. Submitting your designation information online, without more, will not satisfy the regulations's requirements.

To open an Adobe PDF you will need to have the free Acrobat plugin installed. Acrobat is available here.