Serial-no.(SN):
Delivery note no.:
Model:
Stamp of specialist dealer:
Next safety inspection in 12 months
Date:
Place, date:
Signature:
Stamp of specialist dealer:
Next safety inspection in 12 months
Date:
Place, date:
Signature:
Stamp of specialist dealer:
Next safety inspection in 12 months
Date:
Place, date:
Signature:
Stamp of specialist dealer:
Next safety inspection in 12 months
Date:
Place, date:
Signature:
Stamp of specialist dealer:
Next safety inspection in 12 months
Date:
Place, date:
Signature:
65
Recommended safety inspection 1st year
(at least every 12 months)
INSPECTION CERTIFICATE
Electric wheelchair data:
Recommended safety inspection 3rd year
(at least every 12 months)
Recommended safety inspection 2nd year
(at least every 12 months)
Recommended safety inspection 4th year
(at least every 12 months)
Recommended safety inspection 5th year
(at least every 12 months)