BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BUREAU OF AUTOMOTIVE REPAIR | LICENSING PROGRAM
10949 North Mather Boulevard, Rancho Cordova, CA 95670
P (855) 735-0462 F (855) 641-9982 | www.bar.ca.gov
SMOG CHECK TECHNICIAN DUPLICATE WALL LICENSE/
REPLACEMENT BADGE LICENSE REQUEST FORM
INSTRUCTIONS
1. Complete this form to request a duplicate wall license(s) or replacement badge license.
2. Print, sign, and date this form and return it to the address listed in Section B.
SECTION A. LICENSEE INFORMATION
NAME
ADDRESS Number and Street
CITY STATE ZIP CODE
PHONE NUMBER LICENSE #
SECTION B. REQUEST INFORMATION
QUANTITY PRICE TOTAL
FIRST DUPLICATE WALL LICENSE
ADDITIONAL DUPLICATE WALL LICENSES
REPLACEMENT BADGE LICENSE
WALL AND BADGE LICENSE PACKAGE
TOTAL
Make company check, cashier’s check, or money order payable to PSI. No personal checks or cash accepted. Send payment
along with this form to PSI, 3210 EAST TROPICANA, LAS VEGAS, NV 89121
SECTION C. CERTIFICATION
I hereby certify under penalty of perjury under the laws of the State of California that I am the above technician requesting the
duplicate license(s).
SIGNATURE DATE
To obtain a form to request a duplicate adjuster or station license, see the BAR website www.bar.ca.gov or call (855) 735-0462.
BAR-115 3/11/2020
$ 5.00
$ 0.00
$ 2.00
$ 0.00
$ 5.00
$ 0.00
$ 10.00
$ 0.00
$ 0.00
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