STATE OF ILLINOIS

DEPARTMENT OF TRANSPORTATION

VEHICHLE INSPECTION SECTION

2300 SOUTH DIRKSEN PARKWAY

REQUISITION FOR:

1. Certificates of Safety

2. Lane Forms

SPRINGFIELD, ILLINOIS  62764

PHONE:  217/782-2920

PLEASE FURNISH THE FOLLOWING ITEMS

Station No.

Telephone No.

Date

VIR-1

Vehicle Inspection

Report

Name of Station

MSR-1-75-T

Monthly Station Report

(Truck)

Address

MSR-1-75-B

Monthly Station Report

(Bus)

City or Town

Zip Code

SV1-1241

Report of Lost or Stolen

Safety Certificates

Signature of Authorized Person

SV1-1274

Requisition Card for

Supplies

SV1-1280

Defective, Mutilated or

Replacement C/S Report

PLEASE FURNISH THE FOLLOWING C/S'S AND/OR NUMERALS

# PADS

C/S'S OR NUMERALS

TOTAL AMT.

SV1-1312

Rejected Vehicle Card

School Bus C/S's (10 per pad)

Truck C/S's (25 Per pad)

VIR Mailers

ILC.C.Bus C/S's (10 per pad)

Other:

School Bus/LC.C.Inserts – Circle One

1 2 3 4 5 6 7 8 9 10 11 12

IMPORTANT:   Unless the name, address, and telephone number are correct, the Department will not be responsible for delivery of the items requested.

SV1-1274 (Rev. 9-75)