MMR Trailer FormNOTE: In order to comply with FMCSA Safety Regulations, (396), it is necessary for every owner or driver of any leased equipment to fill out this form and submit to Medallion every month. Due Date 15th of each month for the prior month's PM work. No Exceptions.Period Covered*Select monthJanFebMarAprMayJunJulAugSepOctNovDecOwner Name*Address*Driver Name*EquipmentTrailer Make*Unit #*Serial #*Tire Size*Lubrication RecordTractor*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Mileage*Grease*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Mileage*Trailer RepairsBoth date and notes required if marked as such.Brakes*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Springs*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Frame*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Landing Gear*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Kingpin*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Mud Flaps*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Tires*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Rims*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Axles*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Air Hoses/Fittings*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Floor*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Roof (if applicable)*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Miscellaneous*Please SelectRequiredNot RequiredDate* Date Format: MM slash DD slash YYYY Types of Repairs/Service*Tire MeasurementsOther Tires - OVER 2/32Left (Driver side)****Right (Passenger Side)****Brake MeasurementsIf this MMR does not coincide with your Semi-Annual Inspection you can Check the “Box”, which states you have visually check the brakes and drums and found No-Defects.no brake check I have visually checked the brakes and drums and found NO defects.**********I hereby certify that the repair and/or maintenance described above was performed and completedOwner/Driver Signature*Date* Date Format: MM slash DD slash YYYY CAPTCHA
