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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.

SOS-258 (011-02- 4) Page 1 of 2 SUBSTANCE USE EVALUATION (ALCOHOL AND DRUGS) SECTION 1: GENERAL INFORMATION and HISTORY (to …

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