VEHICLE SAFETY INSPECTION FORM

please print legibly Full Name: '?Tacf) Dat e : / ( ') Email: Phone: In spection Type (circle on e ): TNC D ecal#:

Vehicl e Inform ation: VIN ff /)J II, l{l-1 M ak e : 8.A/l vJ Model: ·3 3 5DYe ar: 'AO l 1 # of Do ors L-/

Plat e Numb e r a nd State: _C_u_rr_e n_t _M_i_l e _a =-ge_(.._e _xa_c_,t ),.:'°

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Partner Driver's Signature X Vehicle Inspection Site:

Vehicle Inspection Check List (Please note: All Inspections Must Show 100% to Pass)

Inspection Items Pass Fail Inspection Items Bumpers (no sharp edges) Horn Windshield 0dometer/Speedomet Mirrors (Int/Ext/Rear View Headlights (high/lo Windshield Wipers/Defros �\�r\<e.r \\a.h+�All Passenger Windows Turn Indicators (Open/close properly, Tintlight transmission > 24%) Brake/Back-up light

Doors (open/close/lock) Muffler/Exhuast Driver Seat (AJ;l.i.,.;,��fety Tires (min. 2/32" tre

�hts� (Spare tire, tire jack,

1 Int. , ir bag ,< handle/lugwrench or inflator/sea!er kit)

pms, Etc.) R1A0�\rl; Emergency Brake All Seating Positions Foot Pedals (V\/orking Safety Belts) Foot Brakes (Stopping) Steering/ s us pension

Overall Vehicle Inspection: (All vehicles that pass inspection are good for 1 Calendar Year)

Inspector Name: Certification Number

Pass Fail

X

Inspector Signature x

_\__ Af¢

Comments:

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