Fillable California department of consumer affairs APPLICATION FOR BRAKE ADJUSTER LICENSE

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California department of consumer affairs APPLICATION FOR BRAKE ADJUSTER LICENSE

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R-2A (Rev. 10/14)
Page 1 of 2
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BUREAU OF AUTOMOTIVE REPAIR | LICENSING UNIT
PO Box 989001, West Sacramento, CA 95798-9001
P (855) 735-0462 F (855) 641-9982 | www.smogcheck.ca.gov
For Department Use Only
Registration Number
Issue Date
Class Type
Receipt Number
ATS Number
APPLICATION FOR BRAKE ADJUSTER LICENSE
Class Type of License: Check one only
Class A Class B Class C
INSTRUCTIONS:
1. Read attached instructions and all information contained in this application.
2. Remit fees by check or money order made payable to the Bureau of Automotive Repair.
3. Submit completed application with all requirements and fees to the Bureau of Automotive Repair Licensing Unit at the above
address.
4. All information is mandatory and is required under the Business and Professions Code Section 9887.2 and Labor Code
Section 432.7.
PURSUANT TO BUSINESS AND PROFESSIONS CODE SECTION 158, FEES ARE NON-REFUNDABLE.
If you have a disability or impairment, please refer to the instructions on the reverse side.
Application type: Check one only
Initial (or renewal postmarked more than 30 days after license expiration date) $10.00
Renewal (postmarked on or before license expiration date) $5.00
Late Renewal (postmarked after license expiration date) $7.50
NOTE: The name on this application must match the name on your valid driver license.
You must present the same photo identication at your examination.
Please type or print legibly in ink.
1. Applicant’s Legal Name:
Last First Middle
2. Date of Birth: 3. Social Security Number/Individual Tax Identication Number:
4. Driver License Number: 5. License Number:
(RENEWALS ONLY)
6. Applicant’s Mailing Address:
Number and Street or Post Oce Box
City State Zip Code
7. Business Area Code and Telephone Number: ( )
8. Applicant’s Background: Attach additional sheets if necessary.
a. Have you ever been issued a license by the California Department of Consumer Aairs?
YES NO
If yes, please explain:
b. Have you ever had any license denied, suspended, revoked, or placed on probation by the California
Department of Consumer Aairs?
YES NO
If yes please explain:
c. Have you ever been issued a citation by the California Department of Consumer Aairs?
YES NO
If yes, please explain:
d. Pursuant to Business and Professions Code Sections 480 and 490, have you ever been convicted of
any oense or entered a plea of nolo contendere in this or any other state in the United States?
If yes, you must provide a DETAILED statement, including the crime for which there was a conviction,
the approximate date, location, and sentence served, if any.
(For the purpose of this question, “Oense” does not apply to minor trac violations.)
YES NO
Page 2 of 2
9. Certication:
I certify, under penalty of perjury, under the laws of the State of California, that all the statements made in this application and all the attached
supporting documents pertaining to this application are true and correct.
Signature Date
INFORMATION ON BRAKE ADJUSTER LICENSES
There are three classes of Brake Adjuster licenses. Only one class of Brake Adjuster license may be held at one time
(check only one box on this application). If you wish to apply for Lamp and Brake Adjuster licenses at the same time, two
applications must be submitted. Brake and Lamp Adjuster licenses may be held independently of each other.
The classes are:
Brake Class A: May test, inspect, repair, and certify the braking system on all vehicles, including motorcycles.
Brake Class B: May test, inspect, adjust, repair, and certify the braking systems on trucks 10,000 pounds
GVWR and over. This class may also inspect, adjust, repair, and certify the braking system
on all trailers.
Brake Class C: May test, inspect, adjust, repair, and certify the braking systems on vehicles under 10,000
pounds GVWR, trailers without air brakes, and motorcycles.
Licensed Adjusters may conduct inspections that are required for the issuance of Brake Certicates of Adjustment, and
also certify that corrections have been made when an enforcement document has been issued for brake system defects.
These licenses are not required to perform general repairs on brake systems.
NOTE: Technicians must pass an exam every four years to remain licensed. The license expiration dates will be
adjusted so that they expire in the month of the technician’s birthday. Therefore, the license you receive during
the adjustment period will be valid from 37 to 48 months.
IF YOUR APPLICATION IS ACCEPTED, you will be contacted by the examination service contractor to schedule your
examination.
You must bring two forms of ID to the examination. One must be a photo ID. Read the Candidate Handbook for complete
instructions.
IMPORTANT
If you have a disability or impairment for which you may need assistance during an examination, please call BAR Licensing
at (855) 735-0462 to request an ocial “Special Accommodation Form.” This form must be completed by a health care
professional and be submitted to BAR Licensing with your application.
Per California Civil Code Section 1798.17 (Information Practice Act), the Director of the Department of Consumer Aairs is
responsible for maintaining the information in this application. This information may be transferred to other governmental
and enforcement agencies. Individuals have the right to review the records maintained on them by the agencies, unless
the records are exempt by Section 1798.40 of the Civil Code.
Disclosure of your Social Security number (SSN)/Individual Tax Identication Number (ITIN) is mandatory. Section 30 of
the Business and Professions Code and Public Law 94-445 (42 USCA 405(c)(2)(C) authorizes collection of your SSN/
ITIN. Your SSN/ITIN will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgment
or order for family support in accordance with Family Code section 17520, or for verication of licensure or examination
status by a licensing or examination entity which utilizes a national examination and where licensure is reciprocal with the
requesting state. If you fail to disclose your SSN/ITIN, your application will not be processed And you will be reported to
the Franchise Tax Board, which may assess a $100 penalty against you.
Examination cheating is in violation of Section 123 of the Business and Professions Code. Examination cheating can
result in application denial, suspension, revocation, or restriction of a license. Once the examination begins no talking or
other communication that may compromise examination security is permitted between applicants. Details are contained
in Section 123 of the Business and Professions Code. A copy of Section 123 is included in the Candidate Handbook of
the California Bureau of Automotive Repair Brake and Lamp Adjusters Licensing Examination as well as in the laws and
regulations booklet published by BAR.
NOTICE ON COLLECTION OF PERSONAL INFORMATION
COLLECTION AND USE OF PERSONAL INFORMATION
The Bureau of Automotive Repair of the Department of Consumer Affairs collects the personal information requested on
this form as authorized by Business and Professions Code sections 30, 9884, and 9887.2, Labor Code section 432.7,
Civil Code section 1798 et seq. (Information Practices
Ac
t), and C
a
lifornia Code of Regulations, title 16, section 3310. The
Bureau of Automotive Repair uses this information principally to identify and evaluate applicants for licensure, issue and
renew licenses, and enforce licensing standards set by law and regulation.
Pursuant to Business and Professions Code section 27, the licensee’s address of record is a public record and will be
posted on BAR’s website.
MANDATORY SUBMISSION
Submission of the requested information is mandatory. The Bureau of Automotive Repair cannot consider your application
for licensure or renewal unless you provide all requested information.
ACCESS TO PERSONAL INFORMATION
You may review the records maintained by the Bureau of Automotive Repair that contain your personal information, as
permitted by the Information Practices Act. See below for contact information.
POSSIBLE DISCLOSURE OF PERSONAL INFORMATION
The Bureau of Automotive Repair makes every effort to protect the personal information you provide us. The information
you provide, however, may be disclosed in the following circumstances:
• In respons
e to a Public Records Act (PRA) request (Government Code section 6250 et seq., as allowed by the
Information Practices Act (Civil Code section 1798 et seq.);
• To another government agency as required by State or Federal law; or,
• In response to a court or administrative order, a subpoena, or a search warrant.
Effective July 1, 2012, the California Department of Tax and Fee Administration and the Franchise Tax Board may share
taxpayer information with this agency:
• Your license may be suspended by BAR if your state tax obligation is not paid
CONTACT INFORMATION
F
or questions about this notice or access to your records, you may contact the Bureau of Automotive Repair PRA Unit at
10949 North Mather Boulevard, Rancho Cordova, CA 95670, by phone at (855) 735-0465, or by email at
bar.pra@dca.ca.gov.
F
or questions about the Department’s Privacy Policy, you may contact the Department of Consumer Affairs at 1625 North
Market Boulevard, Sacramento, CA 95834, by phone at (800) 952-5210, or by email at dca@dca.ca.gov.
F
or questions about the Information Practices Act, you may contact the Office of the Attorney General, California
Department of Justice - Attention: Public Inquiry Unit, PO Box 944255, Sacramento, CA 94244, by phone at (800) 952-
5225, or online at
www.privacy.ca.gov.
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Completed 16 December 2019

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