Permit Name: ____________________________________________________Address:________________________
Owners Name______________________________________________________Permit#__________Date:_________
Company No: ___________Make: __________________ Type: ________________Model:_________ Year: ________
VIN #: _______________________________________________ Miles: __________________ Passengers: ______
| Reciprocity sticker ____________ [ ] | Emergency Hammer [ ] | Safety Glass [ ] |
| No Smoking Sign [ ] | Safety Triangles [ ] | Windows Operation [ ] |
| Wipers/ Washer [ ] | First Aid Kit [ ] | Step Condition [ ] |
| Heating System [ ] | Fire Extinguisher [ ] | Hand Grips [ ] |
| A/C System [ ] | Luggage Barrier [ ] | Seat condition [ ] |
| Horn [ ] | Lavatory Emer. Signal [ ] | Seat Width [ ] |
| Lights Operation [ ] | Interior Lights [ ] | Entrance Width [ ] |
| Door Lock Oper [ ] | Drive Shaft Safety Loop [ ] |
Aisle Obstruction [ ] |
| Company Legal Decals [ ] | Emergency Exits Operation [ ] | Driver/Restricted area line [ ] |
| Operated by Decals [ ] | Emergency Exits Signs [ ] | Fuel components [ ] |
| Seating Capacity Sign [ ] | Seat belts present [ ] | Exhaust system [ ] |
| Wheelchair Decals [ ] | Webbing condition [ ] | Brakes components [ ] |
| Wheelchair Lift or Ramp Oper. [ ] | Buckle condition [ ] | Emergency Brake Operation [ ] |
| Wheelchair Securements Present [ ] | Retracting operation [ ] | Front end suspension [ ] |
| W/C Securements Condition [ ] | Tires condition [ ] | Steering components [ ] |
| Mirrors [ ] | Wheel Condition [ ] | Vehicle Overall Condition [ ] |
| Instruments Cluster Oper. [ ] | Fluids leaks [ ] | Chassis and Frame Condition [ ] |
| Malfunction Indicator Lights [ ] | Under Hood Components [ ] | PLATE NUMBER:________________ |
|
REMARKS: NEW [ ]
|
TRANSFER [ ] |
INSPECTIONS ARE VALID FOR 30 DAYS