Restoring Driving Privileges



 

CONTACT US

Drive-To-Work
P.O. Box 14526
Richmond, VA 23221

Phone: (804) 358-6727
Toll Free: (877) 358-6727
Fax: (804) 358-7000
info@drivetowork.org

Application for Services Print This Page

Please fill out the following form online, or click here to download a printable application that can be filled out by hand.

Personal Identification
Your Name  Mr.  Ms. 
 
 FIRST
 
 MIDDLE
  
 LAST
Previous Names (If Any)
Date of Birth
Home Phone
Cell
Other Contact No.
Social Sec. No.
How did you hear
about Drive-to-Work?
U.S. Citizen? Yes No
Legal Residence
Street Apt
City/County-State-Zip
City/County where you Reside
Do you: Own  Rent  Family  (check one)
If you rent, provide contact information:
- Contact Name
- Contact Phone
How long at this address? (mo/yr)
Email Address
Personal Identity Documents
Check all documents that you have:
Birth Certificate
Virginia Drivers License  No.:
Virginia Personal Identification Card  No.:
Criminal Justice Agency Offender Information Form
Social Security Card
US Passport
Other Passport
Employer Check Stubs (two most recent)
Family Information
Married? Yes No    Spouse Name
Living Together? Yes No    Name
Number of dependents
Child support orders (fill out completely):
Name $ / mo.
 
 
 
 
 
Household Income (take-home pay of all residents)  $ per mo.
Employment / Job Training Program
Monthly Income $
Employed? Yes No -- How long?
Self Employed? Yes No -- How long?
Social Security Disability Yes No
Other Income Source
Employer/Name of Business
Employer Address
- Supervisor Name
- Supervisor Phone
Your Position
Your Salary $ per month / $ per hour
Working Hours   Hrs / week
How do you get there?
Time traveling (per day)
Outstanding Garnishments Yes No
Virginia Driving Record
Past Virginia driver's license? Yes No -- License #
Present License Status:
Restrictions/Offenses (check all that apply):
Driving Under Influence (DUI)
Suspend - Not Paying Child Support
Previous Pay Plan Yes No
Suspend - Not Paying Fines and Costs
Previous Pay Plan Yes No
Habitual Offender
Driving On Suspended
Do you have your DMV Driver History Transcript? Yes No
Do you have your DMV Compliance Summary? Yes No
Driving Record: Other States
Have you been licensed in other states? Yes No
List state(s):
Has your license been suspended in other states? Yes No
List state(s):
Pending Traffic Cases
Date Charge Court
     
     
     
     
     
Description of Facts:
Criminal Offender Record (if applicable)
List of Convictions
(offense & sentence):
Time Served Yrs
Place of Incarceration  Release Date
Parole/Probation Officer
Telephone
- Court
Do you have CCRE Report from State Police? Yes No
I Certify that this information is True and Correct
By checking the box above, I certify that all the information in this Application is true and correct. I further understand that no services are promised or will be rendered until this Application is accepted. For services to be provided, a retainer agreement must be signed and any required fees must be paid.
I Authorize the DMV to furnish information regarding my Driving Record
By checking the box above, I authorize the Department of Motor Vehicles to furnish information pertaining to my driving record to Drive To Work.