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 .

3 7. Do you understand that if approved for a restricted license, your license will be restricted to driving for Business Purposes Only as defined in Section 322.271(1)(c), Florida Statutes, and will expire on a specific

  License, Restricted, Restricted license