Date: ____________________

MICA Vehicle: ______________________

Driver Name (please print): ______________________________

Appropriate Tire Condition and Tire Pressure   Yes _____   No ______

Brake Lights Working   Yes  _____  No ______          

Head Lights Working   Yes ______ No ______

Directional Signals Working   Yes ______  No ______

Horn Working   Yes _____   No ______

Windshield Wipers working; Washer fluid adequate   Yes _____ No ______

Rear-view and Side-view mirrors set appropriately  Yes ______  No ______

Under carriage NOT leaking  Yes ______ No ______

Seat belts functional   Yes _____  No _______

Insurance card and Accident Report Form in Glove Box  Yes ______  No _______

Vehicles found to be deficient (with a “No” answer) in any of these or other areas should rectified immediately (tire pressure, fluids, etc.) or reported immediately to the department supervisor.

List any conditions or problems that occur during the trip or from the list above that need to be corrected: _____________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Return this form to your department at the end of your shift.  Department will file report for one year.