RESTORING DRIVING PRIVILEGES

info@drivetowork.org
• (804) 358-6727

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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.

★ = required information

Personal Information

Gender:

First Name:★

Middle Name:

Last Name:★

Previous Names (if any):

Date of Birth★:

Are you as U.S. Citizen?★

Home Phone:

Cell Phone:

Other Contact Number:

Email Address:

Social Security Number:★

How did you hear about Drive-To-Work?★

Legal Residence

Street / Apartment:★

City or County:★

State and Zip:★

City or County where you Reside:★

Name of Residence Owner (if not you):

How Long at this Address (mo/yr) ?★

Family Information

Married?★

Spouse Name:

Living Together?★

Name of Person Living with You:

Number of Dependents:

Child support orders ( fill out completely ):

Household Income (take-home pay of all residents):★

Employment / Job Training Program

Monthly Income:★

Are You Employed?★

Employed How Long?

Self-Employed?★

Self-Employed How Long?

Social Security Disability★

Other Income Source:

Employer/Name of Business:

Employer Address:

Supervisor Name:

Supervisor Phone:

Fax:

Your Position:

Your Salary (monthly / hourly):

Working Hours:

How do you get to Work?★

Time traveling (per day):★

Outstanding Garnishments?★

Court or Agency:★

Personal Identity Documents

Check all documents that you have:

Birth Certificate

Past Virginia Drivers License No.:

Virginia ID or Driver License No.:

Virginia DOC Number No.:

Criminal Justice Agency Offender Information Form

Social Security Card

US Passport

Other Passport

Employer Check Stubs (two most recent)

Virginia Driving Record

Past Virginia Drivers License?

Present License Status:★

Restrictions/Offenses (check all that apply):

Driving Under Influence (DUI)

Suspend - Not Paying Child Support
Previous Pay Plan?

Suspend - Not Paying Fines and Costs
Previous Pay Plan?

Need to consolidate your payments?

Habitual Offender

Drugs

Need to go to driving school★

Driving Record: Other States

Check here if you been licensed in other states. (please list):

Check here if your license been suspended in other states. (please list):

Pending Traffic Cases

Description of Facts:

Criminal Offender Record (if applicable)

List of Convictions (offense & sentence):

Convicted of a Felony?

Time Served (years):

Served at DOC Facility?

Place of Incarceration:

Release Date:

Parole/Probation Officer:

Telephone:

Court:

Certification

Certification:★

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 client retainer agreement must be signed and any required fees must be paid.
Inactive applications will be discarded six (6) months after date received.

I Authorize the DMV to furnish information regarding my Driving Record★
By checking the box above, I authorize the Department of Motor Vehicles to furnish information pertaining to my driving record to Drive To Work.

Processing Fee

$25 processing fee - Method of Payment:★

Client Services

Reasons for Losing Your License & How to Apply

Law Changes

How DTW Advocates for Legal Change

Education

Driving School & Sponsored Programs

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Phone: (804) 358-6727

Fax: (804) 358-7000
info@drivetowork.org