Disconnecting The Passenger Side Airbag (SRS), Approval

To be filled out by the workshop that carries out the procedure:

Car model:

Chassis number:

Registration number:

Odometer reading:

Workshop responsible:

Town:

Date (year-month-day):

To be filled in by the vehicle owner:

Vehicle owner's address:

Post code and town:

I, the undersigned, acknowledge that the front passenger airbag has been disconnected at my request. I understand that the front passenger airbag will not function from the date shown above unless and until the airbag is re-connected. I undertake that I will not remove the decal which indicates that the front passenger airbag has been disconnected and that should the decal be removed or obscured for any reason I will immediately arrange for a replacement to be fitted. I further undertake that I will advise anyone who acquires ownership or usage of the car from me that the front passenger airbag has been disconnected and will provide them with a copy of this form.

Vehicle owner's signature:

Name:

Workshop manager's signature:

Name: