CERTIFICATE OF COMPLIANCE FOR REINSTATEMENT OF PROFESSIONAL OR OTHER LICENSE VA. CODE 63.2-1937 Commonwealth of Virginia CASE NO. DCSE NO. COURT In re/v. PETITIONER RESPONDENT ADDRESS/LOCATION ADDRESS/LOCATION The undersigned respectfully represents to the Court that an order dated was entered by this DATE Court requiring the respondent to surrender his or her license, certific ate, registration, or other authority to engage in a business, trade,profession, or occupation or professional or recreational activity to th e licensing agency. NAME OF LICENSING AGENCY LICENSE NUMBER ADDRESS OF AGENCY Pursuant to the Code of Virginia 63.2-1937, the undersigned requests that the court order the reinstatement of the respondents license, certificate, registration or other authority to engage in a bus iness, trade, profession or occupation or recreational activity to the licensing agency. In support thereof, the undersigned certifies that the respondent has paid the arrears in full. signed a payment agreement and made at least one payment according to th e agreement. complied with the subpoena, summons or warrant or reached an agreement w ith the Department concerning compliance. DATE PETITIONER Attachments: Case Account Statement Certification of compliance or agreement Payment Agreement Other ORDER Upon consideration of certification of payment or compliance as set fort h above, respondents license, certificate, registration, or other authority to engage in a business, trade, profession or occupation or re creational activity is hereby ordered reinstated. Pursuant to Virginia Code 63.2-1937, no fee shall be charged for reinstatement. DATE JUDGE FORM DC-672 (PAGE ONE OF ONE) REVISED 10/02 PDF American LegalNet, Inc. www.USCourtForms.com