Fillable Glass Breakage Form - glass_breakage_form_

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Glass Breakage Form - glass_breakage_form_

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The Glass Breakage Form - glass_breakage_form_ form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Southeastern Louisiana University

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DA 2073
3/93
VEHICLE GLASS REPAIR / REPLACEMENT LOSS NOTICE
AGENCY’S NAME
Southeastern Louisiana University
COMPLETE IF DIFFERENT FROM AGENCY NAME
VEHICLE OWNER’S NAME
ADDRESS
SLU 10452
Hammond, LA 70402
ADDRESS
CONTACT PERSON’S NAME
Jeremy Brignac
PHONE NUMBER
[
985
]
549
-
2157
DATE OF BREAKAGE
TIME
AM
PM
DATE REPORTED
WORK PHONE
[
]
-
HOME PHONE
[
]
-
REPORTED TO
PHONE NUMBER
[
]
-
LOCATION OF VEHICLE
LOCATION CODE
5220
CHECK ONE
STATE VEHICLE OTHER
VEHICLE INFORMATION
YEAR
MAKE
MODEL
BODY STYLE
LIC. / EQUIPMENT NO.
VIN
DID BREAKAGE OCCUR YES
DUE TO ACCIDENT NO
MOTOR VEHICLE ACCIDENT YES
REPORT ATTACHED NO
GLASS DAMAGED __________________________
REPLACEMENT REPAIR
DESCRIBE HOW BREAKAGE OCCURED
DAMAGED AREA INSPECTED BY
PHONE NUMBER
[
]
-
DATE
/ /
IF WINDSHIELD, CIRCLE THE TYPE OF DAMAGE AND INDICATE LOCATION ON DIAGRAM
COMMENTS
SIGNATURE OF AGENCY REPRESENTATIVE
DATE
/ /
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Glass Breakage Form - glass_breakage_form_

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Completed 27 April 2020

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