Form NHTSA Form 1070 NHTSA Form 1070 New Car Request for Dealer Registration

OMB No. 2127-XXXX
Expiration Date: mm/dd//yyyy

DRAFT
New Car Request for Dealer Registration
Consumer Assistance to Recycle and Save (CARS) Program
OEM (i.e., Ford, Mazda, etc.)
Provided by OEM as a formatted data file
Stage 1 – Data Preparation
Dealer Tax Identification
Number (TIN):

Franchise ID of Dealer
(OEM Assigned Unique ID)

Dealer State License Number:

Legal Business Name:

Doing Business As (DBA) / Common Name:
(Name as it will appear on consumer information website)

Physical Address – Line 1:

Physical Address – Line 2:

City, State, 9-Digit Zip Code:

Mailing Address – Line 1 (If
different than above):

Mailing Address – Line 2:

Mailing City, State, 9-Digit Zip Code:

Dealer Contact Name & Title:

Contact Phone:

Contact Email:

Incoming Customer Phone:
Fax Number:

Provided by dealer during online account confirmation
Stage 2 – Validation / Certification
Bank Name:

ABA Routing Number:

Bank Account Number:

I certify the following:
1.
2.
3.
4.

This is a new vehicle dealership with a valid franchise agreement with the vehicle manufacturer.
This dealership will accept the CARS rebate as partial or down payment for the sale or lease of a new vehicle qualified under the CARS
program.
The conditions of voucher eligibility have been read and understood.
I understand that a false statement on this form in connection with this promotion is punishable by law, resulting in fines and/or criminal
penalties.

Signed:

Date:

Version 6/24/2009
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‐XXXX.  Public 
reporting for this collection of information is estimated to be approximately XX  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, 1200 New Jersey Ave, S.E., 
Washington, DC, 20590. 

NHTSA Form 1070