Intake Form for Vermont Mandatory DUI Education Program

Intake Request Form

Please complete this form to request a screening evaluation appointment. NOTE: This is for an appointment only. It is NOT a registration form.

First Name

Middle Initial

Last Name

Date of Birth

YYYY

Telephone Number

(###)

###

####

In what state do you hold a license?

VT Driver License Number (or PID):

Number of driving offenses (DUI/CNN) and approximate date(s)

In what state did the driving offense occur?

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Education Level

Employment

Are you working with Court Diversion (Restorative Justice)?

Did your lawyer recommend you sign up for the course?

How do you plan on paying?