Use this form to request the following items: (1) Certificates of Safety; (2) Decals; and, (3) Forms/Supplies. Make checks payable to Treasurer, State of Illinois. Cash will not be accepted. Mail this form and payment to: Illinois Department of Transportation, Division of Traffic Safety, Commercial Vehicle Safety Section, P.O. Box 19212, Springfield, IL 62794-9212.
Date
/ Telephone Number
/ Station Number
Name of Station
/ Address
City or Town
/ Zip Code
/ Signature of Authorized Person
Truck / Jan - June / Books x 25 = / X / $1.00 = / $
Jul – Dec / Books x 25 = / X / $1.00 = / $
Trailer / Jan – June / Books x 25 = / X / $1.00 = / $
Jul – Dec / Books x 25 = / X / $1.00 = / $
School Bus / Jan - June / Books x 10 = / X / $1.00 = / $
Jul – Dec / Books x 10 = / X / $1.00 = / $
Rebuilt
Books x 10 = / X / $1.00 = / $
Interstate Truck / Jan - Dec / Books x 25 = / X / $1.00 =
$
Interstate Trailer / Jan - Dec / Books x 25 = / X / $1.00 =
$
Total Number of all above C/Ss
Enclosed is: / Check
Cashier Check
Money Order
Number /
For $ / Dated
Please furnish the following:
Qty. / Trucks/SB Inserts
Circle One – 1 2 3 4 5 6 7 8 9 10 11 12 / TS SVI 1241 Report of Lost or Stolen Safety Certificates
Qty. / Trailer Inserts
Circle One – 1 2 3 4 5 6 7 8 9 10 11 12 / TS SVI 1274 Requisition for Supplies
Qty. / Interstate Truck Inserts
Circle One – 1 2 3 4 5 6 7 8 9 10 11 12 / VIR Mailers – Circle – Trk and/or SB
Qty. / Interstate Trailer Inserts
Circle One – 1 2 3 4 5 6 7 8 9 10 11 12
For office use only:
Requisition No.
Printed 1/7/2016TS SVI 1274 (Rev. 01/07/16)