Consumer Application Information


Registered Owner:
Last Name: First Name:
Co-Registered Owner:  
Last Name: First Name:
Mailing Address (Number and Street or P.O. Box):
City: State: Zip Code:
Home Phone Number: Mobile Phone Number:
Email Address:
In What County is Your Vehicle Registered? Gold Shield Station (Optional):
Vehicle Identification Number (VIN): Vehicle License Plate Number:
Vehicle Year: Make:
Model: Odometer Reading (Mileage):
Please indicate your preferred method of contact:
   

Baseline Smog Test Data (For Gold Shield station use only)




   HC CO NOX
Pre 15 Miles per Hour:
Pre 25 Miles per Hour:

Post 15 Miles per Hour:
Post 25 Miles per Hour:


Smog Inspection-Baseline:
Diagnosis:
Smog Inspection-Post Repair:
Total Cost:


CAP Portion Cost:
Consumer Portion Cost:
VRRRM Portion Cost :
Total Cost:



Please click here to submit your Repair application. Once you have submitted your application, you will be directed to Save to PDF. Please save the PDF, sign the document, and submit to a VRRRM-eligible Gold Shield Station selected from our list.