Republic of the Philippines DEPARTMENT OF TRADE AND INDUSTRY Region _______ _________ Provincial Office Control#:

REQUEST FOR HELMET/VISOR ICC STICKERS

Date: Name : Address: Contact No(s).: Brand of Helmet: Date Acquired:
Motorcycle Registration/ Plate No _______________

N
Action:

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.

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

- For issuance Issued ICC Sticker No.:

ToStandards/AuthorizedOfficers: Pleaseencirclenameofpartsifavailable

Printed Name and Signature

FO
-

Other description / identifying marks:

R
- Others:

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.

Findings: - Helmet compliant with BPS MC 1-A:2012

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

Name & Signature of Standards Officer / Date

LE SA