*Indicates required data. You must complete ALL required information. When all required information is entered, click the green Submit button below so that your information is saved. After clicking the Submit button, you must print your application (using the print function) and sign it. Do not print your screen view. Your application is not complete until it is printed, signed and mailed or faxed back to AirCheckTexas Program.
Applicant Information
Middle Initial: *Last Name:
Application Date:
Middle Initial: Last Name:
Email Address:
*Physical Address: (Please include apartment number if applicable)
*Physical City:
*Physical Zip:
*Mailing Address: (Please include apartment number if applicable)
*Mailing City:
*Mailing Zip:
*Telephone #: (enter digits only; no dashes)
Alt. Telphone #:
How did you hear about this program?

Vehicle Information:
*County where vehicle is registered:
Applying for:

*Vehicle Make and Model:
*Model Year:
Please check if your vehicle model is not listed
*License Plate:
*Is the vehicle drivable?
No   Yes

Income Eligibility
Income documentation must be submitted for each adult named on this application. Visit the website for examples of income documents we accept.
*Number of Adults:
Number of Children:
*Adult 1:
*Adult 2:
*Adult 3:
*Adult 4:
*Adult 5: