Vehicle Headlight Inspection Form
Please complete this form to record the results of your vehicle's headlight inspection.
Date of Inspection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspector Name
*
First Name
Last Name
Vehicle Make
*
Vehicle Model
*
Vehicle Year
*
License Plate Number
*
Type of Headlights
*
Please Select
Halogen
LED
HID/Xenon
Other
Condition of Headlights
*
Rows
Working
Dim
Flickering
Not Working
Left Headlight
1
2
3
4
Right Headlight
5
6
7
8
Issues Found
Lens is foggy or yellowed
Bulb needs replacement
Wiring issue
Moisture inside headlight
Other
Inspector's Comments or Recommendations
Submit Inspection
Should be Empty: