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You must complete this form and fax your completed form
to (512) 424-2650 within fifteen days of the date
of your arrest OR the date you were served with
the Notice of Suspension

I want to request an in person hearing and hereby
provide you with the following information in
connection with this request:

Full name:             ________________________________

DOB:                   ________________________________

Texas driver?s license number:  _______________________

____Male            ____Female

Address:_______________________________________________

_______________________________________________________

_______________________________________________________

Telephone number:                   ___________________

Date of arrest:                     ___________________

County of arrest:                   ___________________

Arresting Police Agency:            ___________________

Did you refuse a breath or blood test? _____ yes _____ no

______________________

Your signature

_________

Date