Intake Form for Vermont Mandatory DUI Education Program

Intake 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

MM

DD

YYYY

Telephone Number

(###)

###

####

VT Driver License Number (or PID):

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Education Level

Employment

Email