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@NCRIFS DRIVERS LICENSE RESTORATION INTAKE FORM
****PLEASE READ THE FOLLOWING CAREFULLY****
Thank you for reaching out to NC Reentry Innovators for Success (NC RISE) for assistance in restoring your driver's license privileges. Please fill out the following information to help us understand your situation better.
By completing this form I hereby authorize NC Reentry Innovators for Success to collect, use, and store the information provided in this intake form for the purpose of assisting me with the restoration of my driver's license privileges. I understand that this information will be kept confidential and will only be shared with relevant parties as necessary for the fulfillment of this purpose.
www.ncreentryinnovators.org
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DRIVERS LICENSE RESTORATION INTAKE FORM
Please complete all fields below.
What led to the suspension or revocation of your driver's license?
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Your answer
Have you completed any requirements mandated by the court or DMV related to your license suspension/revocation? (e.g., payment of fines, completion of classes)
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Your answer
Do you currently have any outstanding legal issues or pending charges? If yes, please explain.
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Your answer
First Name:
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Your answer
Middle Name:
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Your answer
Last Name:
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Your answer
Have you ever gone by any other name that your record could be under (such as a maiden name, middle name, common misspelling of your name, etc.)?
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Your answer
Mailing Address (please include apartment number):
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Your answer
Phone number:
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Your answer
Date of Birth:
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MM
/
DD
/
YYYY
Driver’s license or State ID number (your number will only be used to run your record and for no other purpose outside this):
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Your answer
Social security number (your number will only be used to run your record and for no other purpose outside this):
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Your answer
Gender:
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Female
Male
Race:
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Your answer
Do you agree that a law student can work on your case under the supervision of a licensed attorney?
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Yes
No
Have you ever been convicted of a crime in another state or federal court within the past 10 years?
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Yes
No
Maybe
Current monthly income:
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Your answer
Number of people living in your household:
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Your answer
List the type AND amount of any public benefits you are currently receiving (such as SNAP, Medicaid, housing benefits, etc.), if any:
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Your answer
I understand and agree that submitting this form does not create an attorney-client relationship between me, NCRIFS OR attorneys involved. An attorney-client relationship is not created unless and until I sign a representation agreement.
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I understand and agree.
A copy of your responses will be emailed to the address you provided.
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