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2. First Name*
3. Last Name*
5. Address
7. City
8. State
9. Zip
11. Phone*
12. Email*
14. Availability*
    -- Select One --Weekday Mornings (AM)Weekday Evenings (PM)Weekend Mornings (AM)Weekend Evenings (PM)
16. *Appointment Only*

    When requesting an appointment for a Deputy to inspect a car seat, it is important to remember that Deputies work varying schedules and rotations. Therefore, car seat inspections are scheduled by appointment only. Please complete the information on the form below to help provide as much information as possible about the car seat you are using. With this information, the Deputy will be able to better assist you with your seat. Typically, all inspections are done at the Paulding County Sheriff's Office which is located at 180 Constitution Boulevard Dallas, Georgia 30132. An alternate location could be used but it would be at the discretion of the Deputy and have to be previously determined.

20. Vehicle Year
21. Vehicle Make
22. Vehicle Model
24. Car Seat Manufacturer*
    -- Select One --Baby TrendBritaxChiccoCombiEvenfloGracoHarmonyClekOrbitPeg PeregoRecaroDiono (Sunshine Kids)Tomy (Learning Curve, 1st Years, Compass) Dorel (Cosco,Eddie Bauer, Safety 1st, Maxi Cosi)Other
25. Model Number*
26. Date of Manufacture*
    Date of Manufacture
28. Child Age*
29. Child Height*
30. Child Weight (lbs)*
32. Car seat ever been involved in ANY crash?*

    1. Yes
    2. No
    3. Unk

    If yes, it is recommended to discard the car seat and replace immediately.
33. Car seat labels missing?*

    1. Yes
    2. No

    Provides seat specific information
35. Vehicle's Manual Present?*

    1. Yes
    2. No

    Provides details on LATCH System for specific vehicle
37. Car Seat Recall Check
    NHTSA Car Seat Recall List
38. Safe Kids Georgia
    Safe Kids Car Seat Guide
39. Georgia Car Seat Information
    GOHS Child Passenger Safety
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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field