Form Instructions
Revocation Certificate (form A) – for all applicants
1.Print your full name, date of birth, residence and mailing addresses, driver license number and telephone.
2.Provide complete answers to all questions. Do not leave spaces blank.
3.For alcohol/drug related revocations, complete and sign the Authorization To Release Information section.
4.Read the certification statement, then sign and date before a notary public.
5a. For revocations related to alcohol or drugs, submit the Revocation Certificate (form A) to the health professional (see definition on reverse) with the Court Compliance Statement (form B) and Substance Abuse Evaluation (form C); or
5b. For revocations not related to alcohol or drugs, mail only the Revocation Certificate (form |
A) to |
Mail Drop 530M, Driver Improvement Unit, Motor Vehicle Division, P O Box 2100, Phoenix, AZ |
85001- |
2100. The Court Compliance Statement and Substance Abuse Evaluation forms will not be needed. |
|
Court Compliance Statement (form B) – alcohol/drug related revocations only
1.Print your full name, mailing address, driver license number and date of birth.
2.Sign, date and submit the form to the court in which you were convicted of your last DUI in Arizona.
3.The court must return the form to you.
4.After it is returned by the court, submit the Court Compliance Statement (form B) to the health professional with the Revocation Certificate (form A) and Substance Abuse Evaluation (form C).
Substance Abuse Evaluation (form C) – alcohol/drug related revocations only
1.This form must be completed by the health professional.
2.Submit all three forms to the health professional conducting the evaluation. The health professional must review the Revocation Certificate (form A) and Court Compliance Statement (form B), and complete the Substance Abuse Evaluation (form C).
3.The health professional must submit the original of all three forms to MVD.
4.You are responsible for any expenses required to complete the substance abuse evaluation.
MVD Review – All forms/information are reviewed, and you will be notified in writing of the final decision.
Health Professional – The substance abuse evaluation must be completed by one or more of the following:
•Substance abuse counselor who is nationally certified by the Arizona Board of Behavioral Health Examiners, Arizona Department of Health Services or by a comparable board in another state
•Substance abuse counselor who is employed by the federal government and who is practicing in this state
•Physician or psychologist who is licensed to practice in this state, or in any other state
•Physician or psychologist who is employed by the federal government and who is practicing in this state