OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES ALCOHOL / DRUG REINSTATEMENT FILE # PLEASE PRINT OR TYPE LAST NAME STREET ADDRESS PATIENT'S PHONE # FIRST NAME CITY STATE MI ZIP CODE DATE OF BIRTH SOCIAL SECURITY # / DRIVER LICENSE # RELEASE OF INFORMATION I, , hereby authorize and request information regarding my rehabilitation / treatment for chemical dependence on alcohol and / or any other drug of abuse be released to the Driver License Suspensions Section / Special Case Unit, Ohio Bureau of Motor Vehicles. SIGNATURE DATE X STATEMENT FROM LICENSED PHYSICIAN, LICENSED PSYCHOLOGIST, CERTIFIED ALCOHOLISM COUNSELOR (CCDC II, CCDC III, or National Certified) OR PROBATION / PAROLE OFFICER. The above individual has been denied driving privileges in the State of Ohio under provisions of statutory law Section 4507.08 of the Ohio Revised Code. This individual is now requesting that his / her driving privileges be restored. Before reinstatement can occur, it is necessary that the Registrar be in receipt of information which indicates that the individual has successfully completed a rehabilitation / treatment program AFTER the date of their last OVI / Drug offense AND maintained sobriety from alcohol and / or freedom from chemical dependence on any other drug of abuse for a continuous six (6) month period AFTER the treatment / rehabilitation program was completed. Please complete and return this form to the Ohio Bureau of Motor Vehicles, Attention: Driver License Suspensions Section / Special Case Unit, P.O. Box 16784, Columbus, Ohio 43216-6784. NAME OF TREATMENT PROGRAM ATTENDED DATE STARTED YES YES YES NO NO NO Inpatient Program Completed Outpatient Program Completed DATE COMPLETED DATE COMPLETED DURATION DURATION To the best of your knowledge, has the patient maintained a continuous six (6) month period of sobriety AFTER COMPLETION of the INPATIENT / OUTPATIENT PROGRAM? PLEASE NOTE: Do not sign this form until this person has maintained sobriety for six months after completion of the treatment program. Form must be returned to the bureau within ninety (90) days of its completion. Forms more than ninety days old will not be accepted. PHYSICIAN, PSYCHOLOGIST, STATE OR NATIONAL CERTIFIED ALCOHOLISM COUNSELOR, OR PROBATION / PAROLE OFFICER. NAME STREET ADDRESS SIGNATURE TITLE CITY DATE LICENSE # STATE TELEPHONE # ZIP CODE X BMV 2326 8/12 [760-0310] RESTRICTED American LegalNet, Inc. www.FormsWorkFlow.com