NHTSA Form 1483 Notification of Business Change

Part 592.6(l) Notification of Business Change

OMB No. 2127-0002

Exp. 04-30-2017

National Highway Traffic Safety Administration

Import and Certification Division Phone: (202) 366-0115

Website Address: www.nhtsa.dot.gov/cars/rules/import/

NHTSA Form 1483

Use this form to submit the RI's Notification of Business Change to notify NHTSA of relevant changes to the RI business that occurred after the last Yearly Statement was submitted or after the initial application for registration as an importer.

Applicant Name:

Last First

Middle

Date of Birth:

Position:

Business Name:

Business Address: City:

State:

Country

Zip Code:

Telephone Number: Fax Number:

E-mail Address:

Form of Business Organization:

State under which business formed:

Name

Last First Middle

Date of Birth

Position

Owned _%

Business Address

Street, Suite No.

_City State/Province

Country:

Zip Code

Name

Last First Middle

Date of Birth

Position Owned _%

Business Address

Street, Suite No.

_City State/Province

Country:

Zip Code

Name

Last First Middle

Date of Birth

Position

Owned _%

Business Address

Street, Suite No.

_City State/Province

Country:

Zip Code

(Attach a separate page if there are more than 3 partners/officers/directors/managers)

I am willing to contract with individual owners to conform to the safety and bumper standards the following types of vehicles those owners import, provided the vehicles have been determined to be eligible for importation pursuant to 49 CFR Part 593 (check all that apply):
Passenger Cars	MPVs	Light Duty Trucks (10,000 lb GVWR or less)			Trailers	Buses
Heavy Trucks & Tractors (Over 10,000 lb GVWR)			Motorcycles / Motor Driven Cycles	Low-speed Vehicles

Business Address City

State

Country

Zip Code

Telephone Number Fax Number

Date Facility First Used

Date Facility Closed

Same as Main Office

Business Address City

State

Country

Zip Code

Telephone Number Fax Number

Date Facility First Used

Date Facility Closed

Same as Main Office

Business Address City

State

Country

Zip Code

Telephone Number Fax Number

Date Facility First Used

Date Facility Closed

Same as Main Office

Business Address City

State

Country

Zip Code

Telephone Number Fax Number

Date Facility First Used

Date Facility Closed

Principal Name (Last, First and Middle) Title

Principal Name (Last, First and Middle)

Title

Principal Name (Last, First and Middle)

Title

Principal Name (Last, First and Middle)

Title

* Principal, with respect to a Registered Importer, means any officer of a corporation, a general partner of a partnership, or the sole proprietor of a sole proprietorship. The term includes a director of an incorporated Registered Importer, and any person whose ownership interest in a Registered Importer is 10% or more.

Principal Name (Last, First and Middle)

Title

Principal Name (Last, First and Middle) Title

Principal Name (Last, First and Middle)

Title

Principal Name (Last, First and Middle)

*Example: Office Staff - reception, accounting, data entry, mechanic.

**The professional qualifications requirement for the mechanic must be of the applicant or its employees.

Title

Broker Business Name

Business Address City

State/Province

Country

Zip Code

Filer Code

(Custom Broker Filer Code)

Contact Info

Last First

Telephone Number Fax Number

Surety Business Name

Business Address City

State/Province

Country

Zip Code

Surety Code

(CBP Assigned Surety Code)

Contact Info

Last First

Telephone Number Fax Number

Business Name

Business Address City

State/Province

Country:

Zip Code

Contact Info

Last ^First

Telephone Number _{Fax Number}

ICI Name

Business Address

City

State

Country

Zip Code

Contact Info

Last First

Telephone Number

Fax Number

(§ 592.5(a)(3)) Identity of Person preparing this statement (if different from RI.)

Name Title

Business Address City

State/Province ^Country

Zip Code

Applicant's Signature Date

(Signature must be acknowledged by a notary (§ 592.5(A)(12))

Notary's Signature

Date

√ N/A		No.	Enclosures with the following material or information should accompany the Notification of Business Change
		1	A narrated digital DVD video that shows the facilities the applicant proposes to use to conduct its business as an RI. This must be formatted to play in Windows Media Player® or in QuickTime®. Suitable video formats include MPEG® and AVI. The recording must include footage of the office space and office equipment the applicant will use in its RI business, including file cabinets or other devices that will be used to store the records an RI must maintain. The recording must also show the area outside the building as having secure vehicle storage space and the premises inside the building that will be used for performing conformance modifications on imported nonconforming vehicles. (§ 592.5(a)(9)(ii))
		2	If the applicant is a non-public corporation, the applicant must provide a statement issued by the Office of the Secretary of State, or other responsible official of the State in which the applicant is incorporated, certifying that the applicant is a corporation in good standing. The application also must include the full name, street address, and date of birth of each officer, director, manager, and person who is authorized to sign documents on behalf of the corporation and the name of any person who owns or controls 10% or more of the corporation. (§ 592.5(a)(4)(iii))
		3	If the applicant is a public corporation, the applicant must include a copy of its latest 10 -K filing with the Securities and Exchange Commission, and provide the name and address of any person who is authorized to sign documents on behalf of the corporation. (§ 592.5(a)(4)(iv))
		4	If the applicant is a corporation not organized under the laws of a State of the United States, or is a sole proprietorship or partnership located outside the United States, the application must be accompanied by the applicant's designation of a permanent resident of the U.S. as the applicant's agent for service of process in the form specified by 49 CFR § 551.45. (§ 592.5(a)(5)(v))
		5	A copy of the Safety Recall Service Contract the applicant has entered with an independent insurance company, with notarized signatures, to cover the obligations the applicant will incur as an RI with respect to conducting safety recall campaigns. (§ 592.5(a) (8))
		6	A copy of the current business license issued to the applicant to do business as an importer or modifier or seller of motor vehicles or a statement that the applicant has made a bona fide inquiry and is not required by State or local authority to have such a license or document. (§ 592.5(a)(5)(iii))
		7	Information sufficient to establish that the applicant is technically able to modify any nonconforming motor vehicle to all applicable Federal motor vehicle safety and bumper standards. This information should include, but not be limited to, the professional qualifications of the applicant and its employees at the time of the application (such as whether any such persons have been licensed as mechanics), and a description of their experience in conforming and repairing vehicles. (§ 592.5(a)(9)(i))
		8	Information sufficient to establish that the applicant is able to acquire and maintain information regarding the vehicles that it imports and the names and addresses of the owners of the vehicles that it imports or for which it furnishes certificates of conformity to NHTSA in order to notify such owners when a noncompliance or a defect related to motor vehicle safety has been determined to exist in such vehicles. (§ 592.5(a)(9)(iv))

PAPER 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 [INSERT TEXT]. The information is used [INSERT TEXT]. We estimate that it will take approximately 10 hours to complete the form. The information collected is [mandatory/voluntary/required to obtain a benefit; if mandatory or required for benefit, cite statute or regulation]. 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.

NHTSA Form 1483

Page 5 of 7