Determination of Eligibility

By submitting this form, the defendant or their attorney understands that this request will be forwarded to the License Intervention Specialist for determination of eligibility and that a hearing date may be set that the defendant must attend. A defendant or their attorney must provide the proper contact information on this form and understands that the failure to do so may result in the request not being adequately completed. 

Defendent Contact Information
Jr., Sr., II, III, etc.
1234 Street Avenue
Please ensure you enter your email and/or phone number above or your form will not be processed.

General Information


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