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T-215 (Rev. 4-2012)
State of Georgia
Douglas J. MacGinnitie
Vicki Lambert
Department of Revenue
Commissioner
Director
Motor Vehicle Division
P. O. Box 740381
Atlanta, Georgia 30374-0381
(404) 968-3800
Application for Issuance of a Special License Plate & Affidavit of Need & Eligibility
Section I.
Suspended Driver/Habitual Violator Information
Full Legal Name:
Date of Birth:
Address Including City, State & Zip:
Telephone Number Including Area Code:
Driver’s License #:
Surrendered License Plate #:
Date of Conviction:
Court of Conviction:
Have you been convicted of driving two (2) or more times under the influence of alcohol, drugs or other intoxicating substances
YES
NO
within five (5) years?
*** Please attach proof of surrender of the license plate to the Court or local County Tag Agent.
Section II.
Vehicle & Insurance Information
Year & Make Vehicle:
Model Name or Number:
Color:
Vehicle Identification Number:
Insurance Company’s Name:
Policy Number:
Period of Coverage
From Date:
Thru Date:
*** Please attach a copy of the insurance information card for this vehicle provided by the insurer.
Section III.
Status of Suspended Driver’s/Habitual Violator’s Driving Privileges -
Complete this section if the
suspended driver/habitual violator will be operating vehicle.
Attach a copy of driver’s license, when applicable.
Check the applicable box. My driver’s license is stamped ‘limited’ or ‘probationary’.
□
Copy of driver’s license is required.
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My driver’s license is stamped ‘valid in Georgia only’.
Copy of driver’s license is required.
□
My driving privileges have been fully reinstated
Use
Form T-218
My driving privileges are still revoked.
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Complete ‘Alternate Driver’ sections IV, V, VI & VII.
Section IV.
Alternate Driver Information - I hereby certify that the individual named below is a member of my household
and possesses a valid, unrestricted driver’s license.
Attach a copy of the alternate driver’s
license.
Full Legal Name
Date of Birth:
Driver’s License #:
Address Including City, State & Zip:
Telephone Number Including Area Code:
Section V.
Vehicles Registered to Other Household Drivers - If more than one, add additional sheet(s).
Year & Make of Vehicle
Model Name or Number
Vehicle Identification Number
1
2
