Name of Owner *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Please check that all functions are in good working order: *

Brakes

Brake Lights (2)

Head Lights (2)

Tail Lights (2)

Warning Devices/Reflectors (turn signals)

Steering Mechanism

Windshield

Rearview Mirror

Tires (in safe operating condition)

What time of day would be best for an officer to visit you for inspection? *

Morning

Afternoon

Evening

I have reviewed the list of requirements and confirm my under-speed vehicle meets specifications. *

Yes

No

I have a bill of sale including the VIN or serial number that matches the vehicle. *

Yes

No

Someone with a valid driver's license will be present at the time of inspection (this is required). *

Yes

No