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APPLICATION FOR ADMINISTRATIVE HEARING

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Florida Department of Highway Safety & Motor Vehicles Date received by Bureau of ADMINISTRATIVE Reviews APPLICATION FOR HARDSHIP/ ADMINISTRATIVE HEARING . Full Name Date of Birth _________________________. First Middle or Maiden Last Month/Day/Year Mailing Address ________________________________________ ________________________________________ __________________________. Street City State Zip Code Driver License Number _______________________________ State ___________________. Applicant's Telephone Number: Residence ( ) Work ( ) ___________________________________. REASON SUSPENDED OR REVOKED ________________________________________ ________________________________________ ______. WHY DO YOU NEED TO DRIVE? ________________________________________ ________________________________________ __________. I acknowledge that to knowingly make a false statement or conceal a material fact is fraud and may result in the denial of a hardship license. ____________________________.

Application, the sworn testimony I will provide, and/or any written evidence/documents I am or will submit in determining whether my request for a restricted license is granted or denied. I understand I will be contacted for a hearing and that hearings are conducted based on the order in which requests are received.

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