As required by the DOT Federal Motor Carrier Safety Regulations, I submit the following:       (All fields are required.)

 

Date: (ie. MM/DD/YY) Tractor Number: Tractor #: Trailer #:   Indicate whether defects are on TRACTOR or TRAILER. Use sufficient details so that mechanic can locate problem:

Select One Box: I detected no defect or deficiency in this motor vehicle as would be likely to affect the safety of its operation or result in its mechanical breakdown. I detect the following defects or deficiencies in this motor vehicle as would be likely to affect the safety or its operation or result in its mechanical breakdown. Equipment Location: Loaded? Yes No Estimated Departure Time: (ie. "Mon 1900 hrs, Tues 0700hrs") Mileage:

You MUST type in your full legal signature. First and Last name.
Signature: Driver ID:
By typing my signature and driver ID above, and submitting form, I agree that all statements above are lawful and true.