Recovery Program Agent Form

Legal License Specialists Occupational Driver’s License Program

Please give us as much information you can. The more details you provide, the more we're able to help you.

Contact Form

* indicates required field

Name:*

Email:*

Home Phone:

Cell Phone:

Date of Birth:

Social Security Number:

Driver's License Number & State:

ID Number & State:

DL Audit or DD#:

Do you have a copy of your DL?:

Home Address:

City:

State:

Zip Code:

Mailing Address (if different from above):

Employer Name:

Employer Address:

Job Title:

Is your License?:

Do you have surcharge fees that prevent you from getting a licences:

Have you had 2 or more occupational licenses in the last 10 years?:

How you hear about us?:

More Details or Comments about Your Situation:

All Below is for Office Use only: To be filled out by Store Rep: (Agency Name)

Store Location/#:

Rep Name:

Phone Number:

E-mail:

Was SR22 Purchased?:

Was Liability Insurance Purchased?:

Agent Comments: