Restoring Driving Privileges and Drivers License

Drive-To-Work
P.O. Box 14526
Richmond, VA 23221

Phone: (804) 358-6727
Toll Free: (877) 358-6727
Fax: (804) 358-7000
info@drivetowork.org

Restoring Driving Privileges

Application for Services

Please fill out the following form online, or click here to download a printable application that can be filled out by hand.

Personal Identification

Full Name
Previous Names (If Any)
Date of Birth
Place of Birth
Telephone
Cell Contact No.
Social Sec. No.
U.S. Citizen?	Yes No

Legal Residence

Street	Apt
City-State-Zip
Telephone
Do you: Own Rent Family (check one)
If you rent, provide contact information:
- Contact Name
- Contact Phone
How long at this address? (mo/yr)
Email Address

Personal Identity Documents

Check all documents that you have:

Birth Certificate
Virginia Drivers License (expired)
Virginia Personal Identification Card
Criminal Justice Agency Offender Information Form
Social Security Card
US Passport
Other Passport
Employer Check Stubs (two most recent)

Family Information

Married? Yes No Spouse Name

Living Together? Yes No Name

Number of dependents

Child support orders (fill out completely):

Name	$ / mo.

Household Income (take-home pay of all residents) $ per mo.

Employment / Job Training Program

Monthly Income	$
Employed?	Yes No -- How long?
Self Employed?	Yes No -- How long?
Social Security Disability
Other Income Source
Employer/Name of Business
Employer Address
- Supervisor Name
- Supervisor Phone
Your Position
Your Salary	$ per month / $ per hour
Working Hours	Hrs / week
How do you get there?
Time traveling (per day)
Outstanding Garnishments

Driving Record

Past Virginia driver's license? Yes No -- License #

Present License Status:

Restrictions/Offenses (check all that apply):

Driving Under Influence (DUI)
Suspend - Not Paying Child Support
Suspend - Not Paying Fines and Costs
Habitual Offender
Driving On Suspended

Do you have your DMV Driver History Transcript? Yes No

Do you have your DMV Compliance Summary? Yes No

Driving Record: Other States

Have you been licensed in other states?	Yes No
List state(s):
Has your license been suspended in other states?	Yes No
List state(s):
Description of Facts:

Pending Traffic Cases

Date	Charge	Court

Criminal Offender Record (if applicable)

List of Convictions
(offense & sentence):

Time Served	Yrs
Place of Incarceration	Release Date

Parole/Probation Officer
Telephone
- Court

Do you have CCRE Report from State Police? Yes No

I Certify
By checking the box above, I certify that all the information in this Application is true and correct. I further understand that no services are promised or will be rendered until this Application is accepted. For services to be provided, a retainer agreement must be signed and any required fees must be paid.

Remember to send:

- DMV Request Form

- $20.00 Check or Money Order

About Us

Driver's Exam Prep Course