HS 7 Box 3 Registered Importer's Conformity Certification

Statement of Conformity
(June 2006)

RI Name: __________________________

Model Year: ___________________________

Customs Entry #: _____________________

RI #: ______________________________

Make/Model: __________________________

Entry Date: __________________________

Address Where Vehicle Was Conformed:
__________________________________

VIN: _________________________________

Port Code: __________________________

__________________________________

Manufacture Date (Mo/Yr): _______________

Service Insurance Policy #: _____________

Odometer: ________________ [ ] miles [ ] km

Insurer: ____________________________

Vehicle Type: __________________________

Is this your initial certification for this make,
model, and model year? [ ] Yes [ ] No

Address Where Vehicle Can Be Inspected:
__________________________________

Vehicle Eligibility #: ______________________

__________________________________
Conformity to the FMVSS and other applicable requirements has been accomplished by one of the following:
O - Conformed at time of original manufacture

M - Modified to conform after original manufacture

FMVSS

101

Controls and Displays

129 New Pneumatic Tires

220 School Bus Rollover Protection

102

Transmission Shift Lever, Seq-

131 School Bus Pedestrian Safety

221 School Bus Joint Strength

103

Windshield Defrosting, Defogging

135 Passenger Car Brake Systems

222 School Bus Seating/Crash Protection

104

Windshield Wiping and Washing

139 New Pneumatic Radial Tires

223 Rear Impact Guards

105

Hydraulic and Electric Brake Sys-

201 Occupant Protection In Interior

224 Rear Impact Protection

106

Brake Hoses

202 Head Restraints

225 Child Restraint Anchorage Systems

108

Lamps, Reflective Devices, and

203 Impact Protection From Steering

301 Fuel System Integrity

109

New Pneumatic Tires

204 Steering Control Rearward Dis-

302 Flammability of Interior Materials

110

Tire Selection and Rims

205 Glazing Materials

303 Fuel System Integrity of CNG Vehicles

111

Rearview Mirrors

206 Door Locks and Retention Comp-

304 CNG Fuel Container Integrity

113

Hood Latch System

207 Seating Systems

305 Electric-Powered Vehicles

114

Theft Protection

208 Occupant Crash Protection

401 Interior Trunk Release

116

Motor Vehicle Brake Fluids

209 Seat Belt Assemblies

404 Platform Lift Installations

118

Power Operated Window Systems

210 Seat Belt Assembly Anchorages

500 Low Speed Vehicles

119

New Pneumatic Tires

212 Windshield Mounting

120

Tire Selection and Rims

213 Child Restraint Systems

565 VIN Requirements

121

Air Brake Systems

214 Side Impact Protection

567 Certification

122

Motorcycle Brake Systems

216 Roof Crush Resistance

581 Bumper Standard

123

Motorcycle Controls and Displays

217 Bus Exits, Window Retention, Rele

124

Accelerator Control Systems

219 Windshield Zone Intrusion

O

M

N

No. FMVSS

N - Not applicable

No.

O

M

N

No. FMVSS

O

M

N

49 CFR

I state and provide substantiation that: (check only one):
[ ] The vehicle is not subject to any safety recalls as of the time of such certification, or
[ ] All noncompliances and defects that are the subject of safety recalls have been remedied
I certify that: (check only one):
[ ] The vehicle is not required to comply with the parts marking requirements of the Theft Prevention Standard (Part 541), or
[ ] The vehicle, as manufactured or as modified prior to importation, complies with those parts marking requirements.
I certify that: (check only one):
[ ] I know that the vehicle that I am certifying conforms with all applicable Federal motor vehicle safety and bumper standards because I
personally witnessed each modification performed on the vehicle to effect compliance, or
[ ] I know that the vehicle I am certifying conforms with all applicable Federal motor vehicle safety and bumper standards because the person
who performed the necessary modifications to the vehicle is an employee of the above named RI and has provided full documentation of the
work that I have reviewed, and I am satisfied that the vehicle as modified complies.
RI or Designated Representative Signature*: ___________________________________ Printed Name: ____________________________
Designation: ____________________________
HS-7A (Box 3)

(* Must be original, not machine stamp, etc.)

Date: ___________________________________