License Reinstatement Program Application

License Reinstatement Program Financial Affidavit

1. First Name
2. Middle Name
3. Last Name
4. Suffix
5. Date of Birth
6. SSN (last four digits)

Mailing Address

7. Address
8. Apt./Unit #
9. City
10. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
11. Zip

Contact Information

12. Primary Phone #
13. Secondary Phone #
14. Email Address

Employer/Income Information

15. Are you Employed?
    
    
16. Employed Since: Please Select Just Hired Less Than 6 Months Between 6 Months and 1 Year Between 1 Year and 3 Years More Than 3 years
17. Employer Name
18. Address
19. City
20. Employer State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
21. Employer Zip
22. Monthly Employment income (after taxes)

List any other income

23. Other source(s) of income
24. Other income (monthly)

Mailing Option

25. Do you want to receive your LRP Qualification Letter by? US Mail Email
26. BY SUBMITTING THIS FINANCIAL AFFIDAVIT YOU ARE CERTIFYING UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE ABOVE ARE TRUE AND CORRECT.