RESTORING DRIVING PRIVILEGES
info@drivetowork.org
  •  (804) 358-6727
  •  (877) 358-6727

Application for Services 

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

= required information

Personal Information

Gender:
First Name:
Middle Name:
Last Name:
Previous Names (if any):
Date of Birth:
Are you as U.S. Citizen?
Home Phone: 
Cell Phone:
Other Contact Number:
Email Address:
Social Security Number:
How did you hear about Drive-To-Work?

Legal Residence

Street / Apartment:
City or County:
State and Zip: 
City or County where you Reside:
Name of Residence Owner (if not you): 
How Long at this Address (mo/yr) ?

Family Information

Married?
Spouse Name: 
Living Together?
Name of Person Living with You: 
Number of Dependents:
Child support orders ( fill out completely ):
Household Income (take-home pay of all residents):

Employment / Job Training Program

Monthly Income:
Are You Employed?
Employed How Long? 
Self-Employed?
Self-Employed How Long? 
Social Security Disability
Other Income Source:
Employer/Name of Business: 
Employer Address: 
Supervisor Name: 
Supervisor Phone: 
Fax: 
Your Position: 
Your Salary (monthly / hourly):  
Working Hours:  
How do you get to Work?
Time traveling (per day):
Outstanding Garnishments?
Court or Agency:

Personal Identity Documents

Check all documents that you have:
Birth Certificate
Past Virginia Drivers License  No.: 
Virginia ID or Driver License  No.: 
Virginia DOC Number  No.: 
Criminal Justice Agency Offender Information Form
Social Security Card
US Passport
Other Passport
Employer Check Stubs (two most recent)

Virginia Driving Record

Past Virginia Drivers License? 
Present License Status:
Restrictions/Offenses (check all that apply):
Driving Under Influence (DUI)
Suspend - Not Paying Child Support
Previous Pay Plan? 
Suspend - Not Paying Fines and Costs
Previous Pay Plan? 
 
Need to consolidate your payments? 
Habitual Offender
Drugs
Need to go to driving school

Driving Record: Other States

Check here if you been licensed in other states. (please list): 
Check here if your license been suspended in other states. (please list): 

Pending Traffic Cases

Description of Facts:

Criminal Offender Record (if applicable)

List of Convictions (offense & sentence):
Convicted of a Felony? 
Time Served (years):
Served at DOC Facility? 
Place of Incarceration:
Release Date:
Parole/Probation Officer:
Telephone:
Court:

Certification

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.

Processing Fee

$20 processing fee - Method of Payment: