Vehicle Safety Checklist*
AUTHORIZED DRIVERS: All authorized drivers are required to submit a Vehicle Safety Checklist (per vehicle on file) by end of business day (17:00) during the first Monday of every month. Any "No" reponses are causes for concern and corrective action will need to be taken. It is the authorized driver's responsibility to address any "No" responses below.

NOTE: If any statements on this form are found to be false, appropriate actions will be taken.
Sign in to Google to save your progress. Learn more
File No./Employee ID *
Your ID# (If you do not know you ID#, please put 0000)
Employee Name (full name as it appears on your Driver's License) *
Vehicle Make & Model *
Ex. Toyota Camry
License Plate No. *
Driver's License No. *
Driver's License Expiration Date *
MM
/
DD
/
YYYY
Odometer Reading *
The vehicle is equipped with the following in good operating condition:
Adequate rear view mirrors? *
Safety belts? *
Windshield wiper blades and fluid? *
Horn? *
Correctly adjusted headlights? *
Brakes with adequate stopping power? *
Emergency brake? *
Turn/directional signals? *
Good tires with adequate tread and pressure? *
Oil and coolant levels? *
Brake lights? *
Tail lights? *
License plate light? *
Tight muffler system? *
Intact windshield with no crack? *
All seating secured to frame? *
Automobile liability ID card located in the glove compartment or elsewhere in the vehicle? *
Have you been informed of what actions to take in the event you are involved in a vehicle accident? *
I certify that all statements on this form are accurate. I understand that it is my responsibility to fix any "No" responses above. *
Electronic Signature *
By typing in my First and Last Name, I understand that it constitutes a legal signature.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of WINEGRAPE INSPECTION PROGRAM,. Report Abuse
Google Forms