Information

  • Location

Vehicle Used:

  • 2013 GMC Savannah 15 Passenger VIN 1GJZ71FG2D1112448

  • 2015 DODGE Caravan 4PCV Passenger VIN 2C7WDGBG2FR703215

  • 2007 CHEVY Silverado VIN 3GCEC13037G504362

  • 2016 FORD Transit VIN 1FBZX2ZM2GKB25681

  • 2019 DODGE Caravan VIN 2C7WDGBG5KR607282

  • 2019 FORD Transit VIN 1FBZX2CG0KKA52599

  • 2019 FORD Transit VIN KJ061NRB2X950004540

  • OTHER

  • Please indicate

  • Starting Mileage

  • Ending Mileage

  • Conducted on

  • Prepared by

UNDER HOOD

  • Oil

  • Windshield Washer Fluid

  • Battery

  • Hoses/Belts

  • Coolent Leaks

  • Radiator Fluid

  • COMMENTS

SAFETY EQUIPMENT

  • First Aid Kit

  • Bloodborne Kit

  • Flares/Triangles

  • Back Up Alarm

  • Seat Belt Cutter

  • Rear Door Buzzer

  • Accident Kits

  • Fire Extinguisher

  • COMMENTS

WHEELCHAIR LIFT & SECUREMENT

  • Lift Mechanism

  • Lift Belts

  • Safety Plate

  • Manual Pump Arm

  • Shoulder Lap Belts

  • Floor Securement

  • Belts

  • COMMENTS

EXTERIOR

  • Mirrors

  • Tires

  • Head Lights

  • Marker Lights

  • Tail/Brake Lights

  • Turn Signals

  • Windshield Wipers

  • Body Damage

  • Take a Picture of the Damage

  • Cleanliness

  • Doors

  • COMMENTS

INTERIOR

  • Steering

  • Transmission

  • Horn

  • Mirrors

  • Gauges

  • Heater/AC

  • Radio

  • Cleanliness

  • Vehicle Brakes & Parking Brakes

  • Step Well & Dome Lights

  • Emergency Exit

  • COMMENTS

PASSENGER INFORMATION

  • Number of Ambulatory (Passengers Able to Walk)

  • Number of Non-Ambulatory (Passengers Not Able to Walk)

  • Total Number of Trips Made To work site and back counts as 2 trips. If you have 10 passengers and they traveled to the work site and back in the van then the "Total Number of Trips Made" is 20

  • Passenger Names:

  • COMMENTS

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