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Kabupaten/Kota Domisili Perusahaan
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Nomor : ..... Tahun : ...... Jenis Kendaraan : .....
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Contoh : Mobil Barang Bak Muatan Terbuka, box, dll
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Diisi oleh Petugas Dishub Provinsi Jawa Tengah
Diisi oleh Petugas Dishub Provinsi Jawa Tengah

Lihat Proses Ijin Karoseri

Lihat Daftar proses dan kelengkapan ijin karoseri kendaraan bermotor