Seat Belt Convincer Request Form Please use the following form to request a Tennessee Highway Safety Office seat belt convincer to be present at your event. The convincer allows a rider to safely experience the force generated during a 5-10 MPH crash. This force shows how effective a seat belt can be in keeping a person in their seat and reducing movement. A standard power outlet is required to operate the convincer and a 2-inch ball hitch is required to transport the convincer. If the housing department of the convincer is unable to attend your event, your organization will be responsible for: Picking up and returning the convincer to the housing department in a timely manner (no more than 5 business days prior to/following the event) - Operating the convincer as specified in the owner's manual - Assuring that each individual riding the convincer reads and signs a liability waiver (sample provided in owner's manual) - Any monetary costs associated with damage to/from the convincer while in your possession By continuing to complete this form, you agree to the above stipulations. Name Agency E-mail Which convincer are you requesting? - Select -East Tennessee - Housed at UTKCumberland - Housed at Crossville PDMiddle Tennessee - Housed at Rutherford Co. Sheriff's OfficeWest Tennessee - Housed at Shelby Co. Sheriff's Office What day will you be picking up the convincer? Drop Off Date What is the start date of your event? What is the start time of your event? What is the end date of your event? What is the end time of your event? Where will the event be held? Please include full address - street name and number, city and zip code. Tell us about your event: Event title, event purpose, and anticipated audience. Submit