Vehicle Safety or Non-Compliance Report

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

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

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

Vehicle Details
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Vehicle Type:*     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:*	Was the vehicle new or used? New Used	Transmission: Automatic Manual Not Applicable Other
Model:*	VIN / Chassis Number:
Variant:	Approval Number:	Odometer Reading:
Seating Capacity:	Gross Vehicle Mass (GVM)	Gross Trailer Mass (GTM)
		Aggregate Trailer Mass (ATM)

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

Report Attachments