Maintenance
Inspection Form
NAME ____________________________________ MEMBER # __________________________________ DATE _________________________
YEAR _________________ MAKE __________________________ MODEL _________________________ MILEAGE _______________________
VISIBILITY
NOTES/RECOMMENDATIONS
Windshield
Wiper Blades
Mirrors
CRACKED PITTED
Headlights
Park/Tail Lights
Brake Lights
Backup Lights
Turn Signals
Side Markers
License Plate Lights
L
R
LO
HI
LF
RF
LR
RR
L
R
CENTER
L
R
BULLSEYE
L
R
REAR
L
R
INSIDE
LIGHTS
LF
RF
LR
RR
LF
RF
LR
RR
WARNING SYSTEMS
Horn
Emergency Flashers
LF
RF
LR
RR
LUBRICANT/FLUIDS
Engine Oil
Transmission Fluid
Power Steering Fluid
Brake Fluid
Clutch Fluid
Washer Fluid
Engine Coolant
LEVEL
COND
LEVEL
COND
LEAKS
LEAKS
LEVEL
COND
LEAKS
LEVEL
COND
LEAKS
LEVEL
COND
LEAKS
LEVEL
COND
LEAKS
LEVEL
COND
LEAKS
MISSING
LOOSE
CORRODED
MISSING
LOOSE
CORRODED
GREEN
DARK
CLEAR/YELLOW
ANTIFREEZE PROTECTION TEST RESULT:
ºF/ ºC
BATTERY
Carrier/Hold-Down
Cables/Terminals
Charge Indicator
BATTERY TEST RESULT:
BELTS
Serpentine
Alternator
Air Conditioning
Power Steering
Water Pump
Air Pump
WORN
IDLER
TENSIONER
WORN
LOOSE
PULLEY
WORN
LOOSE
PULLEY
WORN
LOOSE
PULLEY
WORN
LOOSE
LEAKS
WORN
LOOSE
PULLEY
UPPER
LOWER
LEAKS
INLET
OUTLET
LEAKS
COND
LEAKS
LO-PRESS
HI-PRESS
LEAKS
INLET
OUTLET
LEAKS
COND
LEAKS
COND
LEAKS
HOSES
Radiator
Heater
Bypass/Other
Power Steering
Transmission Cooler
Vacuum
Fuel (Underhood Only)
OTHER UNDERHOOD
Air Filter
DIRTY
Radiator Cooling Fan(s) MECHANICAL
MISSING
ELECTRIC
TIRES
Pressure (psi) LF
Tread (x/32)
LF
RF
LR
RR
SPARE
RF
LR
RR
SPARE
EVALUATION KEY:
= SATISFACTORY
MINIMUM SAFE DEPTH 3/32”
= NEEDS SERVICE SOON
= NEEDS SERVICE NOW
ACKNOWLEDGEMENT
I have reviewed this Maintenance Inspection Form and understand that it reflects the condition of my vehicle at the time of the inspection only. I recognize that this is a basic visual inspection, not a comprehensive vehicle evaluation, and additional problems may exist in systems and/or components that were not checked as part of this inspection. I accept that this inspection is made without warranty of
any kind, either expressed or implied, or arising by operation of law. I acknowledge that no action has been taken to correct any condition(s) reported, and that the safe operation and maintenance of
the vehicle following this inspection is my sole responsibility. I also agree that the results recorded above may be used in assembling statistics regarding vehicle maintenance, and that copies of this report
may be provided to the program sponsors upon request.
MOTORIST
SIGNATURE
REV. 3/08
FACILITY
NAME / #
SHOP COPY
DATE
Stock # 4123