Request For Eligibility Review printable pdf download

Request For Eligibility Review

STATE OF FLORIDA

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES

BUREAU OF ADMINISTRATIVE REVIEWS

REQUEST FOR ELIGIBILITY REVIEW

Driver Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DL#: - - - - - - - - - - - - - - -

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I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ hereby request a review of my record for the purpose of

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reviewing and determining my eligibility for immediate reinstatement of my driving privilege on a restricted

basis as provided in section 322.2615(1 )(b )3, Florida Statutes. I understand the restriction is for Business

Purposes Only as defined in section 322.271, Florida Statutes and I must pay a $25.00 filing fee for this review,

pursuant to section 322.21(9)(a).

I understand that the restricted license will be for the duration of the suspension period imposed under section

322.2615, Florida Statutes, as follows:

DDriving with an Unlawful Breath-Alcohol or Blood-Alcohol Level = 6 months suspension

DRefusal to Submit to a Breath, Blood or Urine Test= 1 year suspension

Reinstatement of the driving privilege on a restricted basis as set forth herein is conditioned on statutory

eligibility requirements, including but not limited to enrollment in DUI School.

WAIVER OF FORMAL AND/OR INFORMAL REVIEW

I also understand that acceptance of the reinstated driving privilege as provided in section 322.271(7)(c),

Florida Statutes, is deemed a waiver of my right to formal and informal review under section 322.2615, Florida

Statutes.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _

Signature ofDriver

Date:

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Witness Signature

Witness Printed Name

HSMV 72034 (05/2013)

Request For Eligibility Review