Nomad Transit, LLC Los Angeles

19 - Point Vehicle Inspection Form

To be completed by vehicle operator:

Full Name: Email Address:
Phone Number: Date:

To be completed by certified inspector:

INSPECTION POINTS INSPECTION POINTS

Pass Fail Pass Fail
Foot Brakes Doors (Open/Close/Lock)
Emergency Brakes Speedometer
Steering Mechanism Bumpers
Windshield Muffler & Exhaust System
Rear Window & Other Glass Conditions of Tires, Incuding Tread Depth
Windshield Wipers Interior/Exterior Rearview Mirrors
Headlights Safety Belts Driver & Passenger{s}
Tail Lights Front Seat Adjustment Mechanism
Turn Indicator Lights Horn
Stop Lights

To be completed by certified inspector:

INSPECTION SUMMARY
Vehicle Make & Model: VIN #:
License Plate #: Wheelchair Accesible? Yes No
Vehicle Year:

All inspection points must pass in order to pass:

Inspectors, Please circle one option: PASS FAIL

Inspector Name: Inspection Date:
*This certification is valid for one (1) year from certified
Inspection Company: inspection date.

Inspector Signature: Inspection Address: