Requisition Form 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 . 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 Jan - June Books x 25 = X $1.00 = $ Truck Jul Dec Books x 25 = X $1.00 = $ – Jan June Books x 25 = X $1.00 = $ – Trailer Jul Dec Books x 25 = X $1.00 = $ – Jan - June Books x 10 = X $1.00 = $ School Bus Jul Dec x 10 = X $1.00 = $ – Rebuilt Books x 10 = X $1.00 = $ Interstate $ Jan - Dec Books x 25 = X $1.00 = Truck Interstate $ Jan - Dec Books x 25 = X $1.00 = Trailer Total Number of all above C/Ss Check Cashier Check Enclosed is: Number For $ Dated Money Order Please furnish the following: Qty. Trucks/SB Inserts TS SVI 1241 Report of Lost or Stolen Circle One 1 2 3 4 5 6 7 8 9 10 11 12 – Safety Certificates Qty. Trailer Inserts TS SVI 1274 Requisition for Supplies Circle One – 1 2 3 4 5 6 7 8 9 10 11 12 Qty. Interstate Truck Inserts VIR Mailers Circle Trk and/or SB – – Circle One – 1 2 3 4 5 6 7 8 9 10 11 12 Qty. Interstate Trailer Inserts Circle One 1 2 3 4 5 6 7 8 9 10 11 12 – For office use only: Requisition No.
Requisition Form 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 . 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 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.
TS%20SVI%201274.docx