Vehicle Inspection Form Nevada

NEVADA DEPARTMENT OF MOTOR VEHICLES

VEHICLE INSPECTION CERTIFICATE (VIN INSPECTION)

INSTRUCTIONS: This form must be completed by an authorized DMV representative, a licensed Nevada law enforcement officer, or a licensed Nevada vehicle dealer. Please type or print clearly in ink.

I. VEHICLE IDENTIFICATION

• Make: ____________________
• Model: ____________________
• Year: ____________________
• Body Type: ____________________
• Vehicle Identification Number (VIN): ________________________________________
• Odometer Reading: ____________________ (Miles/Kilometers)
• Fuel Type: [ ] Gasoline [ ] Diesel [ ] Electric [ ] Hybrid [ ] Other: __________
• Vehicle Color: ____________________

II. REGISTERED OWNER / APPLICANT INFORMATION

• Legal Name: ________________________________________
• Nevada Driver’s License/ID Number: ____________________
• Residential Address: __________________________________________________
• City: ____________________ State: NV Zip Code: __________
• Phone Number: (_____) _____-__________
• Email Address: ________________________________________

III. INSPECTION DETAILS

• Date of Inspection: _____ / _____ / 20_____
• Location of Inspection: ________________________________________
• Status of Vehicle:
  • Operable
  • Inoperable
• Does the VIN on the vehicle match the supporting documents provided? [ ] Yes [ ] No
• Are there any signs of tampering or alteration to the VIN plate? [ ] Yes [ ] No
• Additional Remarks/Observations: ___________________________________________________________________________ ___________________________________________________________________________

IV. CERTIFICATION AND SIGNATURE

I, the undersigned, hereby certify that I have physically inspected the vehicle described above. I have verified the Vehicle Identification Number (VIN) and the physical condition of the vehicle as noted in this document. I attest that the information provided is true and accurate to the best of my knowledge under penalty of perjury under the laws of the State of Nevada.

Authorized Inspector Name (Print): ________________________________________ Agency/Dealer Name: ________________________________________ License/Badge Number: ____________________

Inspector Signature: ____________________________________ Date: _____ / _____ / 20_____

V. APPLICANT AFFIDAVIT

I, the undersigned applicant, certify that I am the legal owner or authorized representative of the vehicle described herein, and that the information provided is correct. I understand that any false statement made on this document may be grounds for denial or revocation of vehicle registration in the State of Nevada.

Applicant Signature: ____________________________________ Date: _____ / _____ / 20_____

FOR OFFICIAL DMV USE ONLY Processed By: ____________________ Date: _____ / _____ / 20_____