Form Request For Helmet/ Visor ICC Stickers

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