Meter Change Form
This form is intended for the use of agencies and technicians who make adjustments and reseal taxi meters for their company or the industry.
    Use this form to report your meter adjustment activity to Regulators, Weights and Measures or Police Authorities as required in your area.

Repair Agency Number: ________ Agency Name: _________________________________

Technician Name: _______________________ License No. _____________ Exp.:_______

Agency Address:_______________________ City,St,Zip:___________________________

Date: _________________  Time: ___________________ Location: __________________

Client Name: ____________________________________ Contact ___________________

Client Address: ________________________ City,St,Zip:___________________________

Cab No. _______  Medallion No. __________ VIN:_________________________________

Vehicle Year ___________ Make and Model _____________________________________

Meter Brand & Model: __________________ Serial Number:_________________________

Trip Reading At Start: _____________    Trip Reading When Released:________________

Complaint or Condition Before Work:____________________________________________

Work Performed:____________________________________________________________



Calibrate   Reprogram Meter.   Seal Meter   Remove for Shop Repair

Installation   Removal From Vehicle   Removal From Wreck   Repair

Place In Service   Out Of Service    Red Tagged   Red Tag Removed

Supervisory Agency: _____________________ Notified by Fax  Notified In Writing

Technician's Signature _______________________________________________

You May Print and Duplicate this form if no specific form is required by your local
Government Regulatory Agency or by Weights and Measures Department . Keep a copy for your own
records. A service of Fred Stock Electronics 760-345-4347 POBx 12492, Palm Desert, CA 92255-2492.