REVOCATION APPLICATION

Customer (printed) Full Name (first, middle, last, suffix)
Driver License Number
Date of Birth

MonthDayYear
Date
Have you been convicted of any traffic violations in Arizona within the last 12 months? If yes, please provide dates(s) of violation(s)

YesNo
Violation(S) and Date (within the last 12 months)

MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
Authorization to Release Information
I hereby authorize the approved evaluator 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 approved evaluator any actions taken on my Arizona driving record before and after the investigation.
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty: