Vehicle Safety or Non-Compliance Report

Reported By
Fields marked with an aster (*) are mandatory.
Title Miss Mr Mrs Ms Other	First Name *   Required	Last Name *   Required

Organisation (Maximum 100 Characters)		Position
Email *   Required is Invalid		Phone Number
Postal Street Address		Post Code
Country *   Required Australia Other	State	Suburb

Report Type
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Category: *   Required Other Issues Safety Issues Standards Non Compliance Issue	Has there been a death or injury related to this report? *   Required Yes No
Subcategory: *   Required

Vehicle Details
Fields marked with an aster (*) are mandatory.
Vehicle Type:*   Required Component\Part Motor Vehicle Other Trailer	Date Manufactured (mm/yyyy):	Engine / Fuel Type: Diesel Electric Hybrid LPG Not Applicable Other Petrol
	Date Purchased (mm/yyyy):
Make:*   Required	Was the vehicle new or used? New Used	Transmission: Automatic Manual Not Applicable Other
Model:*   Required	VIN / Chassis Number: Max 17 numbers.
Variant:	Approval Number:	Odometer Reading: Max 6 numbers.
Seating Capacity: Max 2 numbers.	Gross Vehicle Mass (GVM) Please enter a numeric value.	Gross Trailer Mass (GTM) Please enter a numeric value.
		Aggregate Trailer Mass (ATM) Please enter a numeric value.

Report Details
Fields marked with an aster (*) are mandatory.
Please describe the matter you are reporting. *   Required
Have you reported this matter to the manufacturer, dealer or supplier? *   Required Yes No
What was the outcome?
Can this information be disclosed to other parties? (i.e vehicle manufacturers, state authorities.) *   Required Yes No

Report Attachments