Blank Arizona Motor Vehicle Division Packet PDF Template

General Instructions

1. Call before submitting this packet, to determine if you are eligible for reinstatement:

Phoenix 602-255-0072, Tucson 520-629-9808, elsewhere in Arizona 800-251-5866

(Hearing/Speech Impaired–TDD systems only: Phoenix 602-712-3222, elsewhere 800-324-5425)

2.Do not submit this packet more than 30 days after the date that it was signed by a health professional.

3.On form C you must list all DUIs and alcohol/drug related offenses (traffic, criminal and out-of-state), convicted or not.

4.Follow all instructions.

5.Incomplete packets will be returned.

Eligibility Requirements

All of the following criteria must be met before you may submit this investigation packet:

1.Your minimum revocation period has elapsed.

2.If your driving privilege was also suspended, the end of the suspension period must have elapsed as well.

3.If your driving privilege was suspended as a result of a judgment filed against you in court (e.g., for damages arising from a motor vehicle accident), that judgment must also be satisfied. The court in which the judgment was filed is to provide a document to us which indicates that the judgment was satisfied. (A mandatory insurance or financial responsibility suspension1 will not prohibit you from completing this packet. However, some actions may require SR-222 insurance.)

4.If your driving privileges are withdrawn, revoked or suspended in another state, you must satisfactorily complete any requirements necessary to reinstate your privilege to drive in that state.

5.If you have any warrants or pending traffic complaints/violations against you, you must first resolve all court-mandated requirements (e.g., payment of fines or penalties) and obtain a written satisfaction from the court.

6.If you have committed any traffic violations within the preceding 12 months, MVD is not authorized to accept your application for reinstatement until 12 months have elapsed since the date of the violations.

1A “mandatory insurance” or “financial responsibility” suspension generally results from the failure to maintain required minimum levels of insurance on a vehicle titled and registered in your name. Whether the suspension is court-ordered or the result of MVD action, a reinstatement fee will be due at the end of the suspension period. If it is a court-ordered suspension, MVD must receive a clearance from the court before driving privileges can be reinstated. Other actions may also be required, depending on the nature of the suspension.

2An SR-22 is a form of high-risk insurance, or proof of future financial responsibility, which may be required in some insurance-related actions. SR-22 insurance may be purchased from any insurance company authorized to do business in Arizona.

Form Instructions

Revocation Certificate (form A) – for all applicants

1.Print your full name, date of birth, residence and mailing addresses, driver license number and telephone.

2.Provide complete answers to all questions. Do not leave spaces blank.

3.For alcohol/drug related revocations, complete and sign the Authorization To Release Information section.

4.Read the certification statement, then sign and date before a notary public.

5a. For revocations related to alcohol or drugs, submit the Revocation Certificate (form A) to the health professional (see definition on reverse) with the Court Compliance Statement (form B) and Substance Abuse Evaluation (form C); or

Court Compliance Statement (form B) – alcohol/drug related revocations only

1.Print your full name, mailing address, driver license number and date of birth.

2.Sign, date and submit the form to the court in which you were convicted of your last DUI in Arizona.

3.The court must return the form to you.

4.After it is returned by the court, submit the Court Compliance Statement (form B) to the health professional with the Revocation Certificate (form A) and Substance Abuse Evaluation (form C).

Substance Abuse Evaluation (form C) – alcohol/drug related revocations only

1.This form must be completed by the health professional.

2.Submit all three forms to the health professional conducting the evaluation. The health professional must review the Revocation Certificate (form A) and Court Compliance Statement (form B), and complete the Substance Abuse Evaluation (form C).

3.The health professional must submit the original of all three forms to MVD.

4.You are responsible for any expenses required to complete the substance abuse evaluation.

MVD Review – All forms/information are reviewed, and you will be notified in writing of the final decision.

Health Professional – The substance abuse evaluation must be completed by one or more of the following:

•Substance abuse counselor who is nationally certified by the Arizona Board of Behavioral Health Examiners, Arizona Department of Health Services or by a comparable board in another state

•Substance abuse counselor who is employed by the federal government and who is practicing in this state

•Physician or psychologist who is licensed to practice in this state, or in any other state

•Physician or psychologist who is employed by the federal government and who is practicing in this state

For a list of eligible substance abuse counselors visit the Motor Vehicle Division website under Driver Services

at www.azdot.gov, or refer to a telephone yellow page directory under Counselor or Alcoholism.

For Alcohol/Drug Related Revocations Only

Authorization To Release Information

Counselor, Physician or Psychologist Name

I hereby authorize the counselor, physician or psychologist above to release to the Motor Vehicle Division any information that is pertinent to my ability to safely operate a motor vehicle, and authorize the Motor Vehicle Division to release to the counselor, physician or psychologist any actions taken on my Arizona driving record prior to and after the investigation.

Certification (For All Applicants)

I have read the eligibility requirements and instructions for reinstatement and I am currently eligible to submit this packet. I have answered the above questions to the best of my knowledge. I understand that if my driving privilege is reinstated, any pending offenses or traffic violations that subsequently result in conviction may result in my permission to reinstate being rescinded or my driving privilege being revoked again. I further understand that if a check of another state’s records or a computer check with the National Driver Registry indicates a suspension or revocation still in existence, my license may be canceled or revoked.

Applicant Signature

Notary or MVD Agent Signature

Acknowledged before me this date.

I am now eligible for reinstatement of my Arizona driving privileges after a revocation. Please provide the following information to be considered by the Motor Vehicle Division.

This section must be completed in full

by court clerk, Arizona Department of Corrections (ADC) parole or probation officer, or judge.

Court Name (for last DUI alcohol/drug related offense in Arizona)

Please attach copies of any documentation establishing compliance/non-compliance.

[Court Seal]

Return Completed Form To Applicant

The applicant above is required by state law to have this evaluation completed in order to be considered for reinstatement of driving privileges in Arizona. Your response on this form will indicate to the Motor Vehicle Division how this person’s substance abuse condition may affect or impair his or her ability to safely operate a motor vehicle. For purposes of deciding whether to reinstate the driving privilege, we may rely on your opinion.

History of all DUIs and alcohol/drug related offenses (traffic, criminal and out-of-state), convicted or not.

Testing instruments utilized in evaluation (a minimum of two standardized testing instruments are required).

Please specify instrument and scores.

Mortimor-Filkins

SASSI

MAST

DRI

Other (standardized test)

Diagnostic Impressions (DSM IV) – Indicate condition/problem and number of prior contacts. Give facts supporting this diagnosis.

Diagnostic Impressions

Based on my evaluation, it is my opinion that the condition of the Applicant:

Evaluator Certification

State law requires all persons who seek reinstatement of Arizona driving privileges following an alcohol or drug-related revocation must provide the Motor Vehicle Division with a current substance abuse evaluation from a:

•Substance abuse counselor who is certified nationally, certified by the Arizona Board of Behavioral Health Examiners, or certified by a comparable board in another state; OR

•Substance abuse counselor who is employed by the federal government and who is practicing in this state; OR

•Physician or psychologist who is licensed to practice in this state, or in any other state; OR

•Physician or psychologist who is employed by the federal government and who is practicing in this state.

I certify that I meet one of the above requirements.

Program Name (if applicable)

()

The originals of this form, the Revocation Certificate (form A) and the Court Compliance Statement (form B) along with a copy of your professional certification/license must be mailed to the address below, within 30 days of the signature date, and a copy provided to the Applicant.

MAIL DROP 530M

DRIVER IMPROVEMENT UNIT

MOTOR VEHICLE DIVISION

PO BOX 2100

PHOENIX AZ 85001-2100