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Driver Information

Full Name

Driver License Number

Social Security Number

Date of Birth

Phone Number

Enter your full mailing address

Applicant address

City

State

Zip Code

Arrest Information

Date of Arrest

Citation Number

County of Arrest

Requested Attendance Method (Required)

Via Telephone or Web ConferenceIn-Person at a Driver License Division Office

If all parties have requested to attend the hearing via live audiovisual means the hearing may be held in a county designated by the division./>

Attorney Information (if applicable)

Attorney Name

Attorney Address

City

State

Zip Code

Retained (attach supporting documents if requesting discovery)Not Retained

Verification

Email address of individual making request

Type full name to sign form

Type full name to Signature of individual making request - type your name here