Driver Compliance Form (Vehicle Inspection)
| Driver First |
Samantha
|
| Driver Last Name |
Rodriguez
|
| Last four of Social | 4098 |
| Pic. of Current DL | |
|
|
| DL Expiration Date | February 9, 2023 |
| Position | Delivery Expert |
| Location |
6700 1425-1 Pleasanton Rd San Antonio, TX 78214 210-924-9200 |
| Is this Team Member a New Hire or Current Employee? | Current Employee |
| Please take a picture of the completed GPS Acknowledgement from GoFormz. | |
| Primary Car? | Primary Car |
| Insurance Information | |
| Name of Insurance Carrier |
Allstate
|
| Policy # |
816546271
|
| Policy Effective Date | June 28, 2021 |
| Policy Expiration Date listed on the Card |
December 28, 2021 |
| Pic of Current Insurance Card with Team Members Name listed as Insured Driver. | |
|
|
| Car Information | |
| Year | 2010 |
| Make | Ford |
| Model |
Fusion
|
| License Plate Number |
HGC0776
|
| Registration Expiration Date | August 30, 2021 |
| Color | Tan |
| Pic of the Car | |
|
|
| FRONT | |
| Does The Vehicle Have Either A Cell Phone Mount Or An Onboard Integrated Hands Free System? |
Yes |
| Is the Drivers Seat Belt Functional? |
Yes |
| Is the Drivers Horn Functional? |
Yes |
| Are both Left and Right High Beams Functional? | Yes |
| Are both Left and Right Head Lights Functional? | Yes |
| Are Both Left and Right Front Turn Signals Functional ? | Yes |
| Are Both Left and Right Front Hazard Lights Functional ? |
Yes |
| The Rear View Mirror Intact and Operational? | Yes |
| Are the Side View Mirrors Intact and Operational? | Yes |
| Tire Condition | |
| Tire condition (Driver Front) PENNY TEST REQUIRED | Yes |
| Photo | |
|
|
| Tire condition (Passenger Front) PENNY TEST REQUIRED | Yes |
| Photo | |
|
|
| Tire condition (Passenger Rear) PENNY TEST REQUIRED | Yes |
| Photo | |
|
|
| Tire condition (Driver Rear) PENNY TEST REQUIRED | Yes |
| Photo | |
|
|
| REAR | |
| Are Both Left and Right Rear Tail Lights Functional? |
Yes |
| Are Both Left and Right Rear Brake Lights Functional? |
Yes |
| Is the Third Brake Light (Center Of Rear Window) Functional? | Yes |
| Are Both Left and Right Rear Hazard Lights Functional? |
Yes |
| Are Both Left and Right Rear Turn Signals Functional? |
Yes |
| Are Both Left and Right Reverse Lights Functional? | Yes |
| MISC. | |
| Windshield Glass | Yes |
| Windshield Washer Fluid | Yes |
| Are the Windshield Wipers and Blades Functional? | Yes |
| Any excessive Body damage? | No |
| Photo | |
| Is Vehicle Free of Any 3rd Party Advertising? | Yes |
| Photo | |
| SIGNATURES | |
Signature of Driver
|
|
| Date | June 19, 2021 |
| Printed Name Of Company Representative |
Alan Vargas
|
Signature of Company Representative
|
|
| Date | June 19, 2021 |
