Driver’s License Restoration Program

Application for Driver License Restoration

Fields marked with an asterisk (*) are required.

First Name *

Last name *

Race *

Sex *

Alias *

Phone Number 1 *

Phone number 2*

Address Line 1*

Address Line 2

City *

Zip *

State *

Driver's License Number

Social Security Card Number? *

Date of Birth *

Age *

Referral Program

Are you Employed?

Residence Status

Education Level

Primary Objective in Getting License *

How Long Have you Been Without a Valid License? *

Acknowledgement Information

I have received a copy of the inquiry. I understand, acknowledge and agree that this is merely an application and does not constitute a contract for services and/or acceptance into the program. I understand that I need to bring back a copy of my suspension detail report(s) provided by The Department of Driver’s Services and my Driving History (MVR) for potential assistance. Determination of program approval will be made after review of application and documents.
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Full Name *

Today's Date *

Time *

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