Determination of Eligibility

By submitting this form, the defendent 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 defendent must attend. A defendent or their attorney will have given 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
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