The following form shall be used to obtain from the applicant the information under oath necessary to assign the proper initial number of points. It may, however, be expanded to require additional information or the sequence of the items may be rearranged:

Date of Application ___________

1. Name of Applicant ____________________________________________________________

                                    First                       Middle                              Last


Driver’s Date of Birth _______________________ Lic. No____________________________________

Previous address during past three years_________________________________________________

2. Other operators of the motor vehicle resident in the same household as the applicant: *

Name                                       Date of Birth                                 Driver’s Lic. No.




* Includes all persons, whether or not related by blood, who are living in the same housing unit or other housing units in continguous family land.

3. Statement of Convictions

Has the applicant or any other person named in (2) been convicted of any of the following motor vehicle violations during the preceding 36 months?


(Yes or No) and Date

(a) Driving while under the influence of alcoholic beverage or other drug

(b) Failure to stop and report when involved in an accident

(c) Homicide or assault arising out of the operation of a motor vehicle

(d) Driving during a period while license is suspended or revoked

(e) Any convictions of other traffic violations.

4. Statement of Accidents

Has the applicant or any person named in (2) been involved in an automobile accident while operating any private motor vehicle, resulting in damage to any property, including his own, or in bodily injury or death during the preceding 26 months?


(Yes or No)

If “Yes”, complete the following:

Date of Accident     Location of Accident       Bodily Injury or Death (yes or no)       Damage to property (amount)




If the answers to any of the following are “Yes’ insofar as they involve the applicant, person residing iii his household, or owner of the automobile being used, so state and give date of accident.

residing in his household was not convicted.

(c) Reimbursed by, or in behalf of, person responsible for the accident or have judgment against such person.

(d) Other person involved in accident was convicted. Applicant or person residing in his household was not convicted.

(e) Damaged by “hit-and-run” driver and accident reported to police within 24 hours from time of accident.

(f) Damage solely by contact with animals or fowl.

(g) Damage solely by flying gravel, missiles, or falling objects.

(h) Accident while responding to emergency call to duty as paid or volunteer member of any Fire department, First aid squad or law enforcement agency.

I am aware that I make this application under oath and that under the laws of American Samoa (29.0107 A.S.C.A.) it is a Felony to knowingly make a material false statement or conceal any material fact in this application. I hereby consent to allow my insurance company to obtain a certified copy of my driving records from the Office of Motor Vehicles at any time subsequent to my completion of this application.

Signature of Applicant Subscribed and sworn to before me this________________day of___________

19_____at______________________, American Samoa.

Signature and Title of person authorized to administer oath

History: Rule 5-78, eff 28 Jun 78, § 9.