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Requested
Illustration:
1.
LIST ALL SPEEDING VIOLATIONS OVER THE LAST
FIVE YEARS:
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
2.
DOES THE CLIENT CURRENTLY HOLD A VALID
DRIVER'S LICENSE?
IF YES, STATE
EXPIRATION DATE
Month
Year
3.
DETAIL LAST MOVING VIOLATIONS OTHER
THAN SPEEDING, IF ANY:
TYPE
DATE:
Month
Year
TYPE
DATE:
Month
Year
TYPE
DATE:
Month
Year
TYPE
DATE:
Month
Year
TYPE
DATE:
Month
Year
TYPE
DATE:
Month
Year
TYPE
DATE:
Month
Year
TYPE
DATE:
Month
Year
TYPE
DATE:
Month
Year
4.
DETAIL ACCIDENTS INVOLVING MAJOR
PROPERTY DAMAGE, IF ANY:
DETAIL
DATE
Month
Year
DATE
Month
Year
DATE
Month
Year
5. WITHIN THE LAST SIX YEARS, LIST THE OCCASION AND THE DATE OF DRIVING UNDER THE INFLUENCE (DUI) ARRESTS AND CONVICTIONS:
None
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
6. HAS THE CLIENT EVER BEEN TREATED FOR SUBSTANCE ABUSE?
IF YES,
PLEASE DETAIL:
Month
Year
7. CLIENTS MARITAL STATUS:
8.
CLIENT'S OCCUPATION
9.
PLEASE LIST ANY OTHER ILLNESSES OR
IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:
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