Fillable Printable Dl Special Review Awareness Form

Dl Special Review Awareness Form

Special Review Awareness

Print and mail, or return in person, this completed application to Driver and Vehicle Services, 445 Minnesota Street - Suite

170, St. Paul, Minnesota 55101-5170. It may also be faxed to (651) 282-2463.

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If you have questions or need additional information, please contact DVS at (651) 296-2025.

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Minnesota Rule 7503.1250 requires individuals with multiple alcohol and/or controlled substance offenses on their driving

record to complete and return the following notice, in addition to meeting all other reinstatement requirements.

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You may not drive until you receive a reinstatement notice!

DL Number (

OMIT DASHES)

Driver's Date of Birth (mm/dd/yy)

PS31086-05 (2/10)

Signature

understand that any alcohol or controlled substances-related incident, not currently a part of my Minnesota driving

record, may result in the cancelation and denial of all driving privileges (including limited privileges for work) in the

State of Minnesota.

Witnessed by:

Subscribed and sworn to before me this day of _______ 20 _____

NOTARY PUBLIC ______________________________________

COUNTY:____________________________

MY COMMISSION EXPIRES_____________

Witness may be a representative of the Department of Public Safety or a Notary

Public.

MINNESOTA DEPARTMENT OF PUBLIC SAFETY

DRIVER AND VEHICLE SERVICES

PRINT OR TYPE:

Name (FIRST, MIDDLE, LAST)

Date (mm/dd/yy)

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