| |
This person is 19 years old or older but is taking the class because of a juvenile suspension that occured before the age of 18. |
| |
This course has been completed as a requirement for being eligible to retain or have my driver license returned due to being under the age of 21 and operating a vehicle with a prohibited level of alcohol in the blood, breath and urine as provided in R.C. 4511.19 (b) or a substantially similar munincipal ordinance. |
| |
This course has been completed as a requirement for being eligible to retain or have my driver license returned due to a twelve point suspension, Section 4510.038 (A). |
| |
I hereby apply to the Registrar of Motor Vehicles to credit two points on my driving record in accordance with Section 4510.037 (c). I am aware that I am not entitled to a two point credit if on this date the total points assessed against my record is less than 2 points or more than 11 points. |
| |
Court Ordered Not For Credit (this student was court ordered to take the remedial course and will not receive the 2 point credit). Forward certificate to court. |
| First: |
|
| Last Name: |
|
| Address Street 1: |
|
| Address Street 2: |
|
| City: |
|
| Zip Code: |
(5 digits) |
| State: |
|
| Daytime Phone: |
|
| Evening Phone: |
|
| Email: |
|
| DOB: |
|
| DL/Permit: |
|
