Date:_____________________

To Whom It May Concern, 

I was arrested for suspicion of DUI, and I am requesting an Administrative 
review of my arrest prior to the Department of Motor Vehicles taking any action 
against my license.  

I am making this request within ten (10) days of my arrest; therefore I am 
entitled to a stay of suspension pending the outcome of this request, APS 
hearing and decision.  If  the Department is unable to schedule the hearing 
within 30 days  of my  request, I additionally request that you send me a 
temporary license and proof that a stay is in place for my driving privilege.

Further, I am requesting that the Department of Motor Vehicles send any and all 
documents that it plans to use in its case in chief, including any subpoena’s 
that may be issued for supplemental testimony in my case.


_______________________________________________________
Name

_______________________________________________________
Street Address:

_______________________________________________________
City                  State                    Zip Code


  Date of Arrest:______________________________________

Arresting Agency:______________________________________

_______________________________________________________
Officer Name and Badge Number

_______________________________________________________
Type of Test Administered

_______________________________________________________
Driver License Number              Driver License State

_______________________________________________________
Signature