DUI?

Name: a/k/a:

Address:

Phone: (Home) (Work)

In what area do you need assistance?
DUI ARD License suspension Traffic offenses PFA violations
Drug charges Assault charges Personal injury

DOB: SSN: Education:

Name & place of employer:

Prior DUI or other: Yes No Explain:

Driver's License No: State:

Issued Date: Expiration:

More than one license? Yes No Explain:

Out-of-State: Yes No Explain:

Address of PennDOT Record:

Is License presently susupended? Yes No For what?

Police Officer's Name:

Department:

Was there an accident involved? Yes No Explain: