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APPLICATION FOR ADMINISTRATIVE HEARING

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. _____. Signature of Applicant Date After completing this form, you may appear or call one of the Bureau of ADMINISTRATIVE Reviews offices listed below for a HEARING .

Lauderdale Lakes 3718-3 W. Oakland Park Blvd, 33311 LauderdaleBAR@flhsmv.gov (954) 677-5800 Miami 7795 W. Flagler Street, Suite 82C, 33144 MiamiBAR@flhsmv.gov (305) 265-3001 Orlando 4101 Clarcona-Ocoee Rd, Suite 152, 32810 OrlandoBAR@flhsmv.gov (407) 445-5581

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