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Owner information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone number(Required)

Email address

Registration (plate number)

Plate type (PAN,CON, etc.)

Vehicle year

Make

Model

Color

VIN number

Current mileage on vehicle

Inspection station name(Required)

Station number (PB/FL#)

Inspection station address(Required)

Street Address Address Line 2 City State ZIP Code

Date of inspection

My complaint is

Emissions related

Safety related

Both emissions and safety

I wish to

Challenge the inspector's decision **

File this complaint

Request an investigation

**Note: If the RMV determines the inspector was correct in failing your vehicle, it will cost you $35

NOTE: please attach a copy of your Vehicle Inspection Report to this form.

Drop files here or

Accepted file types: pdf, jpg, jpeg, Max. file size: 15 MB, Max. files: 1.

Is your vehicle available for inspection during normal business hours?

Yes

No

Location

Description of problem(Required)