Application for Hardship License

Department of Highway Safety and Motor Vehicles Division of Driver Licenses Application for Formal/Informal Review of Driver License Suspension/Disqualification Administrative Suspension/Disqualification

Reason Suspended/Disqualified: ______________________________

Citation Number: ___________

Date of Citation Notice: _____________

County Where Citation/Notice Was Issued: _______________________

Driver License Number: ___________________ State: _______________________ License Surrendered: __________________ To Whom? _________________ Date Surrendered: _____________________

Full Name: ____________________________________________________ First Middle or Maiden Last

Date of Birth: ___________________

Address: ______________________________________________________________________ How Long At This Address: _________________

Mailing Address (If Different From Above): The Law Offices of William R. Moore 100 S.E. 3rd Avenue Suite 2500

Fort Lauderdale Florida Employed By: ______________________________

Employer’s Address: ________________________________________

Applicant’s Telephone :(_____) _________________ Work: (_____) _________________ Area Code Area Code

PLEASE INDICATE BELOW WHICH TYPE OF REVIEW YOU ARE REQUESTING:

I AM REQUESTING A FORMAL REVIEW. (A formal review, a hearing officer is authorized to consider any relevant evidence including the testimony of witness. You may wish to refer to sections 322.2615 (6) and 322.65 (6), Florida Statues, and Rule 15A-6.013, Florida Administrative Code.)

X I AM REQUESTING AN INFORMAL REVIEW. (An informal review a hearing officer is authorized to consider only relevant documents or materials submitted by the officer or the driver. No testimony shall be considered. You may wish to refer to sections 322.2615(5) and 322.64(5), Florida Statues, and Rule 15A-6.018, Florida Administrative Code.)

Applicant’s Signature: _________________________________ Date: __________________