License Reinstatement Application

I want to...

Select all that apply...
Get a Driver's License
Pay Fines I Owe
Register a Vehicle
Discharge a Probation

Applicant Information (Required)

First Name
Middle Name

Last Name
Other Last Names

Address
Apt/Unit
City
State
Zip Code

How long have you lived at your current address?
Email Address
Social Security #
Date of Birth
Driver's License #

Primary Phone
Other Phone

Employment Information (Required)

I am... check only one
Employed
On Disability/SSI
Unemployed and not on Disability or SSI

Only complete if unemployed.

I have other income of...

Only complete if employed.

Employer Name
Contact Person/Supervisor

Employer Address
City
State
Zip Code

How long have you worked there?
Employer Phone

How much do you earn (please indicate weekly, monthly, or yearly)

Household Information (Required)

Spouse (if Applicable)

Full Name
Date of Birth

Employer
Income

Other Adult (if Applicable)

Full Name
Date of Birth

Employer
Income

Monthly Expenses (Required)

Please enter your monthly expenses in each of the below categories.

Utilities (heat, water, electricity)
Food/Groceries

Medical/Dental
Cable/Satellite

Insurance (health, car, home)
Rent/Mortgage

Loan Payments
Credit Card Payments

Telephone
Internet

Child Care
Car Payment

Financial Assistance Received (Required)

Please list details for any assistance you receive.

Food Assistance
FIP

HUD
County Social Services

General Assistance
Energy Assistance

Other Agencies (Crisis Intervention, Salvation Army, Community Action, etc.)

Other Information (Required)

Do you have any pending criminal charges?
Please list the locations (county and state) of criminal charges pending.

Are you currently on probation or parole?
Please provide details about your probation or parole, including the county, state, and probation officer name.

Reference

The following individual can confirm my ability and willingness to participate in this program and make payments. If I am unable to be contacted, I understand the Cerro Gordo County Attorney's Office may attempt to reach me via this individual.

Reference Name
Reference Phone

Address
City
State
Zip Code

Relationship to you

Applicant Statement & Additional Information

I would like to submit the following additional information or special circumstances in support of my application:

I have read and completed all fields that apply to me. I submit the above information and promise that it is true and correct. I understand admission to the program is not guaranteed, is based on the discretion of the Cerro Gordo County Attorney's Office, and may be revoked due to violation of program rules and/or disrespectful behavior.

Signature Please type your full name to serve as an electronic signature.
Today's Date

Attorney

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