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| * Your Name (No division information here) | | |
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| Please state the reason you are filling out the exception survey instead of the standard monthly survey. | | |
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| * Odometer Reading "at time of survey" (Please round off, do not include 10ths of miles) | | |
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| Please enter the last six digits of your vehicle VIN. | | |
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| * The state vehicle is registered in. | | |
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Registration Expiration Date (Only if this has changed since last months survey) |
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Vehicle Maintenance Information |
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Month | Day | Year | | | |
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* Vehicle Lighting * Check to acknowledge each item is in working order or, comment listing any repairs(s) needed. |
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Glass and Mirrors * Check to acknowledge that each item is in working order or, comment listing the repair(s) needed. |
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* Fluid Levels (verify at each oil change)Your answers are based on the information received at the last service completed on this vehicle. |
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* Has this vehicle been involved in an accident within the last 30 days? |
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It is mandatory to report "all" accidents or incidents" If so,have you reported this to Fleet Management, Human Resources, and completed the Vehicle Accident Report Form posted on SharePoint? |
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| Please list any damage to this vehicle. This would include any dents or scratches that were not reported in a prior survey. (A dent is defined as anything larger than a Quarter. A scratch is defined as anything longer than 5 inches). You may be asked to submit photos of any damages. | | |
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* Does your vehicle have secure and lockable area for EFT devices? |
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| * By Entering you name, you acknowledge that you have conducted this inspection and verify its accuracy. | | |
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