02 03 Travel, Photographs and Lifestyle: Form Request For Helmet/ Visor ICC Stickers 04 05 15 16 19 20 21 22 23 24 25 26 27 28 31 32 33

Form Request For Helmet/ Visor ICC Stickers

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Sample Form Request For Helmet/ Visor ICC Stickers. Please note that this form is FREE. You could get a copy of this form at the designated DTI offices or  download this here. If somebody ask for money please report them to the Head of that department.


Republic of the Philippines
Attachment 1
DEPARTMENT OF TRADE AND INDUSTRY – Region
Provincial Office


REQUEST FOR HELMET/VISOR ICC STICKERS
Control #:

Date:

Name : Address: Contact No(s).:
Brand of Helmet:
Date Acquired: Source from/ Bought
from (Establishment/Location):

I certify to the correctness of the above information and futher certify that the helmet has not been subjected to impact, dropped or used during a road accident.




Printed Name and Signature

Note: To be filled out by Standards Officer / Authorized Officer during evaluation:


Brand:

Other description / identifying marks:




Condition of helmet:
a. Safety parts complete & not broken (Shell,
- retention system, protective & comfort paddings
b. No dents, deformation or breakage nor signs of
- cracking or appreciable distortion

- c. No traces of application of paint, stickers, petrol or other solvents
d. Brand name and size still evident on the face of
- the helmet. Brand has not been altered.

- Others:



To Standards / Authorized Officers: Please encircle name of parts if available
Findings:
- Helmet compliant with BPS MC 1-A:2012

- Helmet not compliant with BPS MC 1-A:2012


Action: - Non-issuance
Issued ICC Sticker No.:
- For issuance




Name & Signature of Standards Officer / Date

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