How to prepare for an

Administrative Reviews
You are eligible for an administrative review if you meet one of the following requirements and the licensing action you are appealing does not involve a fatality:  You are a Michigan resident with two or more alcohol and/or drug related driving convictions and you are currently on a restricted license that was approved at a previous license appeal hearing, or
 You are not a Michigan resident and attempting to clear your Michigan driving record. You will not have to appear in person for an administrative review. Instead, the Department of State will review the documents you submit and its own records to determine if your full driving privileges can be reinstated. You will receive a written decision by mail. If the decision is unfavorable, you can still request an in-person or video hearing. You may only request one administrative review in any 12 month period. An administrative review cannot be scheduled until all required documents are received by the department. Please see the reverse side for further information. In Person or Video Hearings
If you request a hearing instead of an administrative review, you must appear live at a hearing site in Michigan. Your appeal will be heard and decided by an attorney-hearing officer, who will either appear live at the hearing site or via video conferencing equipment. Once a hearing has been scheduled you will be notified of the date, time and location. After the hearing, a written decision will be mailed to you. Your rights:  You may bring an attorney with you; however, an attorney is not required.  You may purchase a transcript of the hearing.  If you disagree with the hearing decision, you can appeal the decision to a Michigan circuit court. L E G A L A N D R E G U L A T O R Y S E R V I C E S A D M I N I S T R A T I O N R I C H A R D H . A U S T I N B U I L D I N G  4 T H F L O O R  4 3 0 W . A L L E G A N  L A N S I N G , M I C H I G A N 4 8 9 1 8 1 - 8 8 8 - S O S - M I C H ( 1 - 8 8 8 - 7 6 7 4 2 4 ) Required Forms and Documents
To request either an administrative review or an in person/video hearing, you must submit: Request for Administrative Review or Hearing Substance Use Disorders Evaluation – This report must be dated no more than 90 days prior to If you are requesting an administrative review, you are also required to submit: Other Required Documents
In addition to the above forms, for either an administrative review or an in person/video hearing, you must submit:  A Laboratory Report from a 10-Panel Urinalysis Drug Screen – This report must include at least two integrity variables such as specific gravity, urine creatinine or pH level.  An Ignition Interlock Final Report – If you were previously approved for a restricted license with the ignition interlock device, you must submit the Ignition Interlock Final Report from the interlock vendor.  Evidence of Support – Alcoholics Anonymous (AA) sign-in sheets, letters, or other evidence that shows you are attending a structured support group. If you have a sponsor, you should also include a notarized letter from that person.  Documentation of Sobriety –Your sobriety must be confirmed by a cross-sampling of your friends, family and co-workers, who are in a position to know, observe and personally attest to your habits regarding the use of alcohol and/or controlled substances. Three to six letters must be signed, dated and notarized with a complete mailing address and telephone number where the writer can be reached between 8 a.m. – 5 p.m. EST. Letters should be as current as possible and must contain the following information about you:  The person’s relationship to you.  How often the person sees you.  How long the person has known you.  The last time the person saw or had knowledge of you drinking or using controlled  The amount of alcohol or controlled substance the person knows you consumed on the last  What social activities you participate in involving alcohol or controlled substances.  The person’s knowledge of your past or current involvement in treatment or a support group.  Other information the person believes is important.  Additional Evidence – If you have ever attended a license appeal hearing, please refer to your last hearing order for any additional information you may be required to submit. You may also submit any other evidence you believe is relevant to your case.
The information you provide will assist the department in determining whether to restore your driving
privileges. However, please be aware that submitting this information does not guarantee you will be
approved for a license or a clearance.

Michigan Department of State
Administrative Hearings Section
P.O. Box 30196 ● Lansing, MI 48909-7696
Fax: 517-335-2190
Full Name ___________________________________________________________________________________________ (Please print exactly as it appears on your driver’s license or personal identification card issued by the State of Michigan.) Street Address ________________________________________________________________________________________ City of Residence ________________________State_____________ ZIP Code _____________ Birthdate _____________ Michigan License Number ________________________________________________ Telephone _____________________ (8 a.m. - 5 p.m.) Attorney’s Name ____________________________________________________________ Bar Number______________ (If retained for this matter) Attorney’s Address ____________________________________________________________________________________ Attorney’s Telephone __________________________________ Attorney’s Fax ___________________________________ OPTION I - Administrative Review (This option is only available to Michigan residents seeking the removal of restrictions or
to non-Michigan residents attempting to clear your Michigan driving record. The licensing action being appealed cannot involve a
___I am requesting an administrative review and have enclosed all documents as requested, including the Petitioner’s Affidavit (Form 3). I understand that the administrative review will be based on the written proofs that I submit along with this form, and that the department may or may not accept additional evidence. I understand that previous license appeal orders may be considered in making a decision. I also understand the administrative review will not be recorded and that no testimony will be taken. I further understand the decision will be mailed after the administrative review has been completed. Selecting this option does not affect my eligibility for a hearing. OPTION II - Hearing (Check all that apply)
___I will personally attend a hearing regarding the restoration of my driving privileges. I will be notified of the scheduled ___I am a deaf or deaf-blind person. I understand I have the right to a qualified interpreter and that the Department will make arrangements for a qualified interpreter to appear at the hearing. ___I will need a foreign language interpreter. I understand that I must provide my own foreign language interpreter, that my foreign language interpreter must be qualified and that I cannot have a family member, friend or other interested person serve as my foreign language interpreter. Signature ________________________________________________ Date ____________________________________ PLEASE FORWARD THIS FORM AND ALL REQUIRED DOCUMENTATION TO:
Michigan Department of State
Administrative Hearings Section
P.O. Box 30196 ● Lansing, MI 48909-7696
Fax: 517-335-2190
SECTION 1: GENERAL INFORMATION and HISTORY (to be completed by driver/applicant)
Please print or type. Attach additional pages where necessary. Lifetime Conviction History: List all driving convictions (e.g., operating while intoxicated or impaired driving) and non-driving convictions (e.g., drug
crimes, domestic violence, MIP, or disorderly persons) involving alcohol or controlled substances. Include juvenile dispositions.
Bodily Alcohol Content or
Bodily Alcohol Content or
Drug Type
Drug Type
I authorize the Evaluator named on Page 2 to furnish the information set forth on this form and to discuss the information with the Michigan Department of
I understand this form may also be used as my written request for hearing. I certify that my responses contained in this document are true and accurate to
the best of my knowledge and belief.

SECTION 2: HISTORY and EVALUATION (to be completed by evaluator)
Please print or type. Attach additional pages where necessary. Lifetime Treatment History for Alcohol and/or Drug Use Disorders: Attach each treatment plan and discharge report.
Program Type
(e.g., Detoxification, Residential/Inpatient, Name of Program,
Beginning and
Treatment Outcome
Intensive Outpatient, Outpatient [individual Therapist or Group Leader,
Ending Dates
and Location
Medication assisted treatment (e.g., Methadone, Antabuse, Buprenorphine, or Campral): Medication: _____________________________ Prescribing Physician: ______________________________ Lifetime Support Group History: List all time periods of attendance and frequency.
Period Frequency
Sponsor Yes or No?
Diagnostic Impression (DSM-IV): Indicate all past and present alcohol, drug and mental health diagnoses.

Supporting facts for diagnostic impression:
Course specifiers (check all that apply):
Testing Instruments: Attach the actual instrument used.
Testing Instruments Used
Explain how the results of this test
Score Interpretation
correlate with the DSM-IV diagnosis on Page 1
Drug Screen: Administer a 10-panel urinalysis drug screen (or refer client) and submit a current laboratory report that includes at least two urine integrity
variables. Please include the confirmation test for any positive screen results.
If you administered an ethyl-glucoronide alcohol test, what were the results? Lifetime Abstinence History:
Period of Abstinence
Abstinence Period Abated by What?
(Any abuse of prescription medication or use of Comments
alcohol, controlled substance, or NA beer) Client Prognosis:
Please check one:
Provide supporting facts for this prognosis (consider the client’s current living and work environments, lifestyle, relapse history, use of
addictive prescribed medications, and any other relevant factors that may affect the overall prognosis):

Alcohol and/or NA Beer: _________________ Controlled Substances:____________________ (Including illicit drugs and addictive prescription medications) Continuum of Care Recommendations:
Please check all that apply:
(e.g., AA/NA, Women for Sobriety, SMART Recovery) Reasons for recommendation or if none, please state reasons:

Certification of Evaluator:
As of this date, I certify that I have reviewed Section 1 and completed Section 2 and that this Substance Use Disorders Evaluation and Request For Hearing is true to the
best of my knowledge and belief based on information obtained from the client, the client’s known substance use disorder and mental health history, and a client
examination. I understand that the decision to grant, suspend, or reinstate an individual’s driving privileges rests solely with the Department of State, which may consider
other facts or conditions when making this decision.
Evaluator’s Name (printed or typed)
Evaluator’s Signature

Proof of Residency
1. Are you currently a resident of Michigan? _____ Years of Residency: ________ If yes, proceed to Line (7)
2. If you are not a resident of Michigan, why did you leave and when? _________________________________
3. Are you a permanent resident of another state/country?_____ If yes, where? (Please attach proof of residency if you are
a resident of a state other than Michigan) _____________________________________________________________________________________
4. When did you become a permanent resident of your current state? __________________________________ 5. Why are you applying for clearance of your Michigan license? _____________________________________ _______________________________________________________________________________________ 6. Do you intend to re-establish residency in the state of Michigan anytime in the future? _____ If yes, When?
Conviction History (Please attach all out-of-state driving records, if applicable)
7. In your lifetime, have you ever had a license in another state(s)? _____ If yes, please indicate the state and
license number(s): _______________________________________________________________________ _______________________________________________________________________________________ 8. In your lifetime, how many times have you been convicted in Michigan or any other state of an alcohol and/or controlled substance-related driving offense, such as drunk or impaired driving? ______________________ explain: __________________________________________________________________________ 9. In your lifetime, have you ever been convicted of any alcohol and/or controlled substance related offenses that did not involve driving, such as domestic violence, disorderly conduct, etc? __________________________ Please explain: __________________________________________________________________________ 10. In your lifetime, have you, as a driver, ever been involved in a crash in which someone was injured or killed? _____ If yes, please explain: _______________________________________________________________ 11. In your lifetime, have you ever been incarcerated, on probation or parole for one or more alcohol and/or controlled substance related offense(s) (driving and non-driving)? _____ If yes, please indicate the offense, where and when it occurred, and the release date: _______________________________________________ _______________________________________________________________________________________ 12. Do you currently have a case pending against you in any state, for any offense, driving or non-driving? If yes, please indicate the location, court date and the nature of the offense. ________________________________ _______________________________________________________________________________________ 13. When was the last time you were convicted of any civil infraction, misdemeanor, or felony (driving or non- driving?) _______________ Please indicate the conviction, the date, and location of the offense. _________ _______________________________________________________________________________________
Alcohol and/or Controlled Substance History
14. Describe your past drinking habits and controlled substance use in detail. Include how often you consumed
alcohol and used controlled substances, what kind(s) and the amount typically consumed/used per occasion. _______________________________________________________________________________________ _______________________________________________________________________________________ 15. Describe your current drinking habits and controlled substance use in detail. Include how often you consume alcohol and/or use controlled substances, what kind(s) and the amount typically consumed/used per occasion. _______________________________________________________________________________________ 16. When did you last consume alcohol? _______________ What kind(s), and what was the amount consumed? _______________________________________________________________________________________ 17. When did you last use an illicit drug and what drug did you use? ___________________________________ _______________________________________________________________________________________ 18. When did you last consume non-alcoholic beer (i.e. Sharp’s, O’Doul’s, etc.)? _______________ What was the amount of non-alcoholic beer consumed? __________________________________________________ 19. What is your intention as to the future use of alcohol/controlled substances? __________________________ 20. Do you agree that your substance use disorders evaluation accurately describes your alcohol/controlled substance use history and your current status? _____ If no, please explain: ___________________________ _______________________________________________________________________________________ 21. Are you currently taking any prescribed medications? ___________ If yes, please list all medications and the medical conditions for which you are taking them, and for how long._____________________________ _______________________________________________________________________________________ Treatment History
22. Have you participated in or successfully completed a substance abuse counseling or treatment program? ___
If yes, please state the name of the program(s), date(s), location(s), frequency of attendance and any other relevant information. Please attach verification of completion. ____________________________________ _______________________________________________________________________________________ 23. Have you ever attempted abstinence from alcohol and/or controlled substances? _____ If yes, when and for how long did you maintain total and complete abstinence? ________________________________________ 24. Have you ever abstained from alcohol and/or controlled substances while incarcerated, or while on probation or parole? _____ If yes, when and for how long did you abstain? ___________________________________ 25. Have you ever used alcohol and/or controlled substances after a period of abstinence? _____ If yes, please list date(s) and reason(s). _____________________________________________________________________ _______________________________________________________________________________________ Continuum of Care
26. Are you currently attending a community-based or 12-step support program? _____ If yes, please state the
name of the program(s), date(s), location(s), frequency of attendance, name of sponsor (if any), and any other relevant information. Please attach verification of attendance and statement from sponsor (if applicable). __ 27. Are you currently involved in any other recognized recovery program? _____ If yes, please state the name of the program(s), date(s), location(s), frequency of attendance, and any other relevant information. Please attach verification of attendance. ____________________________________________________________ 28. If you are not currently a member of an organized self-help program or other recognized recovery program, do you have an informal support system you rely upon to help you maintain abstinence? _____ If yes, what is the nature of this support system? __________________________________ Please provide documentation. Additional Information
29. Please provide any additional information you feel is relevant to your appeal. You may attach additional
pages if necessary.

________________________________________________ _____________________________

Subscribed and sworn to by __________________________ before me on the Signature: ________________________________________ Printed name: ____________________________________ Notary Public, State of ______________, County of_______ My commission expires _____________________________ Acting in the County of _____________________________


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