RAASAP Online Application for Services Form
Complete this application for any RAASAP services that are not court ordered.
Email address *
What is your full name? *
If a previous client, please provide any different name you may have had at that time:
What is your date of birth? *
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DD
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What is your Social Security Number? *
What is your driver's license number? *
What state is your DL issued by? *
What phone number can you be reached at? *
What is your mailing address? *
What service(s) are you applying for? *
Required
If applying for DMV/Administrative enrollment, please list the court(s) and date(s) of your DUI conviction(s)
If you have any out-of-state DUI offenses, please list court(s) and date(s) of your conviction(s):
For DMV/Administrative or Non-VASAP cases: did you have a Virginia license at the time of your conviction?
Clear selection
For DMV/Administrative or Non-VASAP cases: did you complete education and/or substance abuse treatment counseling in another state for your DUI(s)? If so, when?
Do you have any pending alcohol- or drug-related charges? *
Have you received services from RAASAP before? *
Do you owe any fees to RAASAP or to any other Virginia ASAP location? *
Provide any additional info that is important to share:
Acknowledgements
I understand that I must submit a copy of my Compliance Summary from the Virginia Department of Motor Vehicles along with this online application by mailing or dropping it off to the RAASAP office or faxing it to (540) 645-6304. I understand that after my application is reviewed and approved, I will be advised to the cost, which is due in full at the time of application and that no payment plans are available for voluntary enrollment services. I understand that if I owe RAASAP or another ASAP, I will have to pay any past due balance before any new services will be approved. I understand that fees paid to RAASAP are NON-REFUNDABLE, and that it is ultimately my own responsibility to know what services I require, and if I am unclear as to what requirements I have to satisfy in order to regain my driving privileges, I should seek legal advice from an attorney or seek clarification from any agency referring me to RAASAP for any services PRIOR TO ENROLLMENT. I understand that RAASAP is only responsible for providing the service that I have applied for.

I certify that I have answered all of these questions to the best of my ability and knowledge. If I failed to disclose information that affects my eligibility for enrollment, my case can be closed without refund.
By typing my name below, I acknowledge the statements immediately preceding this section. I will also be sent this document to e-sign in acknowledgement that I affirm the contents and responses to all questions are true and accurate to the best of my ability and knowledge: *
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