TO: Texas Department of Public Safety, fax #: (512) 424-2650

Please type or print clearly                 Date faxed :____________________________

Name:______________________________________________________________

Current Mailing Address (WARNING: DPS may mail notices of hearings and other important information to the address on your driver's license - update it immediately), including City, State, ZIP Code:

___________________________________________________________________________________________

Home Telephone Number __________________________________________________________________

Work/daytime Telephone Number ____________________________________________________________

Driver's License Number Issuing State _________________________________________________________

Date of Birth __________________________________________

Date of Arrest _________________________________________________________________

County of Arrest ________________________________________________________________

Arresting Agency ____________________________________________________________________________

Arresting Officer and Badge Number, if known _______________________________________________________

Are you requesting an in-person hearing or telephone hearing? Circle one ---- in-person/telephone

I HEREBY REQUEST A HEARING FOR THE PURPOSE OF (Check only one)

__________ FAILED TEST: Contesting the suspension of my driver's license and/or driving privilege based on alleged failure of breath/blood/urine test, the result being allegedly 0.08 or greater.

__________ REFUSED TEST: Contesting the suspension of my driver's license and/or driving privilege based on alleged refusal of breath/blood/urine test.

******* The request for hearing must be received by the Texas Department of Public Safety no later than fifteen (15) days after you have been served with notice of suspension, which is normally served on the day of arrest. It is advisable that you fax this document and get a printed confirmation that the fax was sent and received before the deadline.

This form is provided as a courtesy by attorney Phillip W. Goff and does not establish an attorney-client relationship.