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Order ID

First Name

Last Name

Justice of the Peace OR County

Number

County

Offense

Current Mailing Address

Current Mailing City

Current Mailing State

Current Mailing Zip

Country

Phone Number

Email Address

Date of Birth

Last 4 Digits of social security number

Driver's License Number

Driver's License Number State

Driver's License Expiration Date

Is your license suspended because of a physical or mental disability?

Yes

No

Is your license suspended for non-payment of child support?

Yes

No

Have you had 2 or more occupational driver's licenses in the last 10 years because of convictions?

Yes

No

Is your license suspended under Transportation Code section 521.342.

Yes

No

Criminally Negligent Homicide? (Penal Code section 19.05)

Yes

No

Driving While Intoxicated? (Penal Code section 49.04)

Yes

No

Driving While Intoxicated with Child Passenger? (Penal Code section 49.045)

Yes

No

Flying While Intoxicated? (Penal Code section 49.05)

Yes

No

Boating While Intoxicated? (Penal Code 49.06)

Yes

No

Assembling or Operating an Amusement Ride While Intoxicated? (Penal Code section 49.065)

Yes

No

Intoxication Assault? (Penal Code section 49.07)

Yes

No

Intoxication Manslaughter? (Penal Code section 49.08)

Yes

No

Date of Conviction

Court of Conviction

County of Conviction

Were you arrested and the breath sample provided registered above 0.08?

Yes

No

Were you arrested and refused to give a breath sample, as requested?

Yes

No

Date of Arrest

Within the past ten (10) years from the date of the arrest that led to your current Driver License suspension, have you had a suspension for refusal to give a breath/blood sample or for providing a sample with a blood alcohol content greater than 0.08 following an arrest for a DWI?

Yes

No

I was convicted of an offense.

Yes

No

A Texas court determined that I am a "habitual violator of traffic laws?"

Yes

No

A Texas court ordered me to attend a Driver Education Program and automatically suspended my license, permit and/or driving privilege for 365 days?

Yes

No

Do you have any criminal charges pending?

Yes

No

You do not need to consider traffic or Class C charges.

Yes

No

Does the suspension of your Driver License have a start and end date?*

Yes

No

Start Date:

End Date:

Why do you need an Occupational Driver License? (Check all that apply.)

I need to drive to and from work.

I need to drive myself or my family member(s) to and from school.

Other Reasons.

Employer’s Address:

Employer’s Telephone:

Days and hours you work:

Job title:

I am self-employed as:

My work address is:

Start:

End:

Start:

End:

Start:

End:

Start:

End:

Start:

End:

Start:

End:

Start:

End:

School #1 Name:

Telephone:

Address:

School #2 Name:

Telephone:

Address:

Counties you drive through:

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