VIA Mobile360 Pre-Installation Checklist and Requirements Questionnaire

Fill out the form below:

1. Company Name *

2. Business Email *

3. Supervisor Information - Onsite contact (Name/Phone/Email) *

4. Worksite Address *

5. Site Specific Training *

6. MSA/MSHA/Insurance Requirements *

7. Site Plan (Available Amenties) *PowerWaterBathroomIndoorOutdoorWeather Contingencies (i.e. lighting shutdown)Open Flame PolicyOther

8. Onsite Resources *OperatorTechnician (for In House Installation)Fabricator for Custom Brackets (for In House Installation

9. Hours of Work (Start/Stop) *

10. Available to Work After Hours? *YesNo

11. Available to Work Weekend? *YesNo

12. PPE Required *HardhatSteel Toe ShoesGlovesVestSafety GlassesHearing ProtectionOther

Vehicles

Vehicle Make/Model/Year *

Is Vehicle a Forklift? *YesNo

Fuel Type *GasElectricDieselOther

System Voltage *

Vehicle Images *All 4 SidesROPS Bar (If Applicable)Roof (If Applicable)Photo of Diagnostic Port

Upload image file(s) *

Drag and Drop (or) Choose Files

Review Installation Proposal *Check if we can drill into the vehicle bodyCheck if epoxy is okay to use

Special Requirements

Preferred Placement Configuration for M500/FSS SystemsLRB (1 Left, 1 Right, 1 Back)2F1F (2 Front 1 Back)2B1F (2 Back 1 Front)

Minimum Clearance from ROPS (Applicable to Forklifts)

Minimum Clearance from Sides (Applicable to Forklifts)

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