ALR Hearing Request

PRO SE ALR HEARING REQUEST FORM

(Print, complete, & fax this form to (512) 424-2650 within fifteen days of the date of your

arrest or the date you were served with the Notice of Suspension / DIC-25.)

Dear Sir/Madame:

I want to request an in-person ALR hearing and hereby provide you the following information in connection with this request:

Full Name: ________________________________

D.O.B.: ________________________________

Texas/or other state: _____________ Driver's License No...