Form NHTSA Form 1259 NHTSA Form 1259 Part 566 - Manufacturer and Product Identification

0MB No. 2127-0043
Expiration Date: XX/XX/XXXX

Manufacturer and Product Identification Form
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 0MB Control Number.
The 0MB Control Number for this information collection is 2127-0043. Public reporting for this collection of
information is estimated to be approximately 15 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, W51-316, 1200 New Jersey Avenue, SE, Washington, DC 20590.

NHTSA Form 1259

0MB No. 2127-0043
Expiration Date: XfJX'IJXXfY..

Part 566 - Manufacturer and Product Identification
Submission Type:

[lRe\fisioh :Cf

Initial

Full Name of Company
For U.S. Manufacturers,
State of Incorporation,
if applicable

All Names the Company is
Doing Business As (OBA)
Company's Principal Officer
or Owner
First

Last

Position

Company Address
Street No., Suite No.
City

__________ State/Province ________ Country _________ Postal Code ______

CompanytHeadquarters
Address
Street No., Suite No.
City

__________ State/Province ________ Country _________ Postal Code

Company/Plant
Address
Street No., Suite No.
City

__________ State/Province ________ Country _________ Postal Code ______
Company Contact Information
Telephone

Submitted by Company Official
Printed Name

E-mail Address ----------------Web-site

Date
Company Position ___ _____________

Signed By

Section I. • f::quipme11t

NHTSA Form 1259

Date

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