Form NHTSA Form 1721 NHTSA Form 1721 End of Visit Release Agreement

OMB Control Number: xxxx-xxxx

Expiration Date: xx/xx/xxxx

End Of Visit Release Agreement (EVRA)

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to 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 XXXX-XXXX (expiration date: MM/DD/YYYY). Responding to this collection of information is estimated to be approximately 2 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. 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

Please select the mode of safe transportation you will Somebody I personally know will pick me up, and be taking after today's visit: they will be sober

I will get a ride from a rideshare company (e.g., Uber, Lyft) at my own expense

I will get a ride from a taxi (Yellow Cab) at my own expense

Name of Subject

(Please type your First and Last Name)

Signature of Subject

(Click "Add signature" to sign)

Date of Signature

(Use the "Today" button to enter today's date)

Name of Researcher

(Please type your First and Last Name)

Signature of Researcher

(Click "Add signature" to sign)

Date of Signature

(Use the "Today" button to enter today's date)

NHTSA Form 1721