Restored Offender Evaluation Packet
For Habitual/Multiple/Third Offenders to complete as part of their petition to their local Circuit Court for full or partial license restoration
Email address *
What is your full name? *
Your answer
What is your social security number? *
Your answer
What is your current address? *
Your answer
How long have you lived at this address? *
What is a good phone number to reach you at? *
Your answer
What is your date of birth? *
MM
/
DD
/
YYYY
Do you own or rent your current residence? *
Who do you live with? *
What is your marital status? *
How many children do you have? *
If you have children what are their ages?
Are your parents still living? *
How often are you in contact with your mother (if alive)? *
How often are you in contact with your father (if alive) *
How many brothers or sisters do you have? Where do they live? How often are you in contact with them? *
Your answer
What is the highest level of education that you have completed? *
What is the year did you complete the level of education you indicated on the previous question? *
Your answer
Were you ever in the military? *
If so, what branch of the military do/did you serve in?
If you served or are serving, when did you serve?
Your answer
If you served, what type of discharge did you exit the service with?
Are you currently working, disabled, or unemployed? If working, what is your occupation? *
Your answer
Please list your current or previous employers and your job title for the past five years: *
Your answer
Do you have any medical conditions? If so, please list any medications you currently take. *
Your answer
Have you ever received substance abuse treatment counseling or hospitalization where alcohol or drug use was part of the issue? *
If you said yes to the previous question, where and when did you receive these services?
Your answer
At what age did you have your first drink of alcohol? What type of alcohol was it? *
Your answer
Describe in your own words your current alcohol consumption (frequency, type, and quantity), or list the date you last consumed: *
Your answer
If you have quit drinking, describe your consumption pattern prior to quitting (frequency, type and quantity): *
Your answer
Have you ever tried any of the following? *
Required
For any that you tried in the previous question, what age did you try them and when did you last use them. Also describe what age you were at your peak use and the amount of your peak use: *
Your answer
Please list your DUI convictions to the best of your memory: *
Your answer
Please list any Drunk In Public/Public Intoxication convictions/charges you received to the best of your memory: *
Your answer
Please list any underage possession of alcohol convictions, or possession of drugs (and type) convictions to the best of your memory: *
Your answer
Do you have any pending charges related to drugs, alcohol, or driving without a license? *
Please provide the name, mailing address and phone number of your first character reference: *
Your answer
Please provide the name, mailing address and phone number of your second character reference: *
Your answer
Please provide the name, mailing address and phone number of your third character reference: *
Your answer
Please provide the name, mailing address and phone number of your fourth character reference: *
Your answer
Please provide the name, mailing address and phone number of your fifth character reference: *
Your answer
If you are being represented by legal counsel for your petition, please provide your attorney's name. Your evaluation will be mailed to their office when completed.
Your answer
Which circuit court are you petitioning? (In most circumstances, this should be the circuit court in the county/city where you live) *
What date is your petition hearing currently scheduled? *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of Rappahannock Area ASAP. Report Abuse