Transcription of APPLICATION FOR ADMINISTRATIVE HEARING
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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 . NOTE: A $ filing fee must be collected prior to scheduling your hardship HEARING . A $ filing fee must be collected prior to scheduling your ADMINISTRATIVE HEARING . Office Hours - Monday through Friday 8:00 to 5:00 Orlando Office Hours Monday through Friday 7:00 to 6:00 City Address Office Number Fax Number Clearwater 4585 140th Avenue North, Suite 1002 (727) 507-4405 (727) 507-4406.
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
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