Out-Of-Area Emissions Exemption Form
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2Out-of-Area Emissions Exemption
Application for Exemption from Arizona Emissions Testing
for Vehicle(s) Registered Outside the Emissions Test Area
An Out of Area Exemption is issued for vehicles registered outside of the emissions control area, but within zip codes which
include emissions testing or on Gila River Tribal lands. By signing this form, the applicant affirms that the vehicle(s) listed are not
operated within the emissions control area for employment or school. See complete instructions below and on next page.
Address Verification
Name:
Physical Address: (No Post Office boxes)
City and Zip:
County:
Telephone:
E-mail:
Do you commute
Vehicles used to commute into emissions test area: If someone in your household commutes into the
emissions test area for employment or is a full time student at an Arizona college or university, please
to work or
check box at left and complete the information below. Vehicles used to commute into the area for work or
school?
school must pass emissions inspection. ARS 49-542A. Any other vehicles may be exempted.
□
□
Employer:
Employer Address:
NO
YES
See
See
College or University:
Campus Address:
Exempt
Used to
from test
Commute
Vehicle Identification
List all vehicles at this address
Commute
License
Vehicle Identification Number
Year/Make
Registration
Plate Number
/Exempt
Month
If you checked “Yes” above, please list any vehicle(s) used to commute first. These will not receive exemption and must be tested.
Used to
commute
Used to
commute
Exempt From Test: List below all vehicles you wish to have exempted from emissions testing (not used to commute). You
must include a copy of the registration for each vehicle and a utility bill showing physical address above (see instructions):
Exempt
from test
Exempt
from test
Exempt
from test
Exempt
from test
Exempt
from test
Applicant’s Signature________________________________________________
Date:____________________________
Making false statements on this application is a violation of ARS 49-550D, and considered an act of perjury.
PRINT FORM
CLEAR FORM
For Office Use Only: Do not write below this line
Section: _______________________________ Township: _____________________________ Range: ______________________________
Verified by: _________________ Process date: _____________Approved: ___ Denied: ___ Rejected:___ Out-of-Area Exemption 140423
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