Transcription of SUBSTANCE USE EVALUATION (ALCOHOL AND …
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SUBSTANCE USE EVALUATION (ALCOHOL AND …
SOS-258 (01-02-14) Page 1 of 2 SUBSTANCE USE EVALUATION (ALCOHOL AND DRUGS) SECTION 1: GENERAL INFORMATION and HISTORY (to be completed by driver/applicant) Please print or type. Attach additional pages where necessary. PLEASE KEEP COPIES OF ALL DOCUMENTS (INCLUDING THIS FORM) THAT YOU SUBMIT. Name (First, Middle, Last) Date of Birth Driver s License Number Street Address Telephone Number 8 5 City State ZIP Lifetime Conviction History: List all driving convictions ( , operating while intoxicated or impaired driving) and nondriving convictions ( , drug crimes, domestic violence, MIP, or disorderly persons) involving alcohol or controlled substances. Include juvenile dispositions. Driving Convictions Date Bodily Alcohol Content or Drug Type (If known) Nondriving Convictions Date Bodily Alcohol Content or Drug Type (If known) I authorize the Evaluator named on Page 2 to furnish the information set forth on this form and to discuss the information with the Michigan Department of State.
SOS-258 (01-02-14) Page 2 of 2 Testing Instruments: Attach the actual instrument used. Testing Instruments Used (e.g., ASI, SASSI-3, MAST/DAST) Score Interpretation of …
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