Florida Department of Highway Safety and Motor Vehicles Bureau of

Florida Department of Highway Safety and Motor Vehicles

Bureau of Administrative Reviews

HSMV 72034 (Rev. 3/2024)

REQUEST FOR ELIGIBILITY REVIEW

Full Name: _________________________________________________ Date of Birth: _________________

First Middle or Maiden Last MM/DD/YYYY

Mailing Address: _________________________________________________________________________

Street City State Zip Code

Driver License Number: _____________________________________ State: _________________________

Telephone Number: (_____) ________________ Email Address: __________________________________

I hereby request a review of my driving record for the purpose of determining my eligibility for

immediate reinstatement of my driving privilege on a restricted basis as provided in Sections

322.2615(1)(b)3 and 322.271(7), Florida Statutes.

By requesting the reinstatement of my driving privilege, I request the Bureau of Administrative Review (BAR)

waive the hearing requirement pursuant to Section 322.271(2)(b), Florida Statutes, and determine my eligibility

for a restricted license based on this Application and any written evidence/documents I am submitting.

I understand that the restricted license will be for the duration of the suspension imposed under Florida law, as

follows: Six (6) months for Driving with an Unlawful Breath-Alcohol or Blood-Alcohol Level, or one (1) year

for a Refusal to Submit to a Breath, Blood, or Urine Test. Reinstatement of the driving privilege on a restricted

basis as set forth herein is conditioned on statutory eligibility requirements, including enrollment in DUI

School.

APPLICATION QUESTIONS

Please answer all the below questions.

1. Have you ever been issued a driver license in any other state? Yes No. If you checked “Yes” to

the above question, in which state? _______________________________________________________

2. Have you ever been convicted of any alcohol related offense in any other state? Yes No. If you

checked “Yes” to the above question, list the state and the offense. ______________________________

____________________________________________________________________________________

3. Do you understand that if your driver license is currently suspended for an unlawful blood/breath alcohol

level or refusal to submit to a breath/urine/blood test, and you are subsequently convicted of DUI in a

criminal court, a restricted license received via this Application will no longer be valid? Yes No

4. Do you understand that if approved for a restricted license, your license will be restricted to driving for

Business Purposes Only as defined in Section 322.271(1)(c), Florida Statutes, and will expire on a specific

date? Yes No

DatereceivedbyBAR

ITEMS TO SUBMIT WITH THIS APPLICATION

Please submit a $25.00 filing fee via check or money order made payable to the Division of Motorist Services

with this Application. Please do not send cash. Your application will not be considered complete until the filing

fee is received.

Please also submit a copy of your Florida DUI Uniform Traffic Citation and proof of enrollment in DUI School.

If the school is not completed within 90 days of enrollment, your restricted license will be cancelled.

OATH OR AFFIRMATION AND WAIVER OF FORMAL/INFORMAL REVIEW

I swear or affirm that all information provided above is true and correct. I acknowledge that knowingly making

a false statement or concealing a material fact may result in the denial of a restricted license. I also understand

that acceptance of the reinstated driving privilege is deemed a waiver of my right to a formal or informal review

under Section 322.2615, Florida Statutes.

Signature of Driver: __________________________________ Date: _____________________

Signature of Witness: _________________________________ Date: _____________________

Printed Name of Witness: ______________________________

PLEASE MAIL YOUR APPLICATION TO THE OFFICE NEAREST TO YOUR RESIDENCE

PLEASE DIRECT ANY QUESTIONS TO THE SAME OFFICE VIA EMAIL

OFFICE ADDRESS EMAIL ADDRESS

Clearwate

4585 140th Ave N., Suite 1002, 33762 ClearwaterBAR

flhsmv.

Jacksonville 7439 Wilson Blvd, 32210 JacksonvilleBAR

flhsmv.

Lauderdale Lakes 3718-3 W. Oakland Park Blvd, 33311 LauderdaleBAR

flhsmv.

Miami 7795 W. Fla

ler Street, Suite 82C, 33144 MiamiBAR

flhsmv.

Orlando 4101 Clarcona-Ocoee Rd, Suite 152, 32810 OrlandoBAR

flhsmv.

Pensacol

100 Stumpfield Road, 32503 PensacolaBAR

flhsmv.

Tallahassee 2900 Apalachee Pkw

, Room B154, 32399 TallahasseeBAR

flhsmv.

Tamp

2814 East Hillsborou

h Ave, 33610 TampaBAR

flhsmv.