"Application for Reprieve of Fifteen-Year License Revocation" - Nebraska

Application for Reprieve of Fifteen-Year License Revocation is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

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Download "Application for Reprieve of Fifteen-Year License Revocation" - Nebraska

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APPLICATION FOR REPRIEVE
OF
FIFTEEN-YEAR LICENSE REVOCATION
Name:
Last
First
Middle
Social Security Number:
List below all the names or surnames you have used or been known by and describe when,
how, and why your name was changed.
Last, First, Middle
Used From
Used To
Description of Change
Sex:
Male
Female
Date of Birth: Month
Day
Year
Place of Birth (City, State, Country):
Name, address, and phone number of legal counsel (if any):
Name
Address
Legal Counsel Phone (
)
Your mailing address for the next six months:
Address
P.O. Box
Apartment
City
County
State
Zip Code
Country
License revocation you are seeking to have commuted:
Date of Offense
County of Offense
Date of Sentencing
Other 15-year Revocations:
Have you received any other lifetime or 15-year license revocations?
Yes
No
Date of Offense
County of Offense
Date of Sentencing
Date of Offense
County of Offense
Date of Sentencing
Attach an additional sheet if necessary.
- 1 -
APPLICATION FOR REPRIEVE
OF
FIFTEEN-YEAR LICENSE REVOCATION
Name:
Last
First
Middle
Social Security Number:
List below all the names or surnames you have used or been known by and describe when,
how, and why your name was changed.
Last, First, Middle
Used From
Used To
Description of Change
Sex:
Male
Female
Date of Birth: Month
Day
Year
Place of Birth (City, State, Country):
Name, address, and phone number of legal counsel (if any):
Name
Address
Legal Counsel Phone (
)
Your mailing address for the next six months:
Address
P.O. Box
Apartment
City
County
State
Zip Code
Country
License revocation you are seeking to have commuted:
Date of Offense
County of Offense
Date of Sentencing
Other 15-year Revocations:
Have you received any other lifetime or 15-year license revocations?
Yes
No
Date of Offense
County of Offense
Date of Sentencing
Date of Offense
County of Offense
Date of Sentencing
Attach an additional sheet if necessary.
- 1 -
Personal Information
1. Give name and age of the following:
a. Spouse (or former spouse)
b. Children
How many live with the applicant?
c. Father
d. Mother
e. Sisters
f.
Brothers
2. State the highest grade of education you have completed:
3. Name and address of high school:
4. Any higher education degrees completed:
5. Have you ever been a member of the United States Armed Forces?
Yes
No
a. If “yes”, what branch?
b. Active
Reserve
6. Dates of duty:
7. Date of discharge:
8. Type of discharge:
- 2 -
Addresses Since the Date of the Order of Revocation
List every permanent and temporary residence you have had since the date of the order of
revocation. All periods of time must be accounted for. List addresses in reverse chronological
order starting with your current address.
Current Address From Mo./Yr.
Address
Apt.
City
County
State
Zip
Country if not United States
To Mo./Yr.
From Mo./Yr.
Address
Apt.
City
County
State
Zip
Country if not United States
To Mo./Yr.
From Mo./Yr.
Address
Apt.
City
County
State
Zip
Country if not United States
To Mo./Yr.
From Mo./Yr.
Address
Apt.
City
County
State
Zip
Country if not United States
To Mo./Yr.
From Mo./Yr.
Address
Apt.
City
County
State
Zip
Country if not United States
To Mo./Yr.
From Mo./Yr.
Address
Apt.
City
County
State
Zip
Country if not United States
Attach a separate sheet if necessary to include all addresses.
- 3 -
Employment
List every job you have held since the date of the revocation order beginning with your current,
or most recent, job. Include self-employment, temporary, and part-time employment. Account
for any periods you were unemployed.
To Mo./Yr.
From Mo./Yr.
Employer
Supervisor
Address
City
County
State
Zip
Country if not United States
Phone (
)
Occupation
Reason for Leaving
To Mo./Yr.
From Mo./Yr.
Employer
Supervisor
Address
City
County
State
Zip
Country if not United States
Phone (
)
Occupation
Reason for Leaving
To Mo./Yr.
From Mo./Yr.
Employer
Supervisor
Address
City
County
State
Zip
Country if not United States
Phone (
)
Occupation
Reason for Leaving
To Mo./Yr.
From Mo./Yr.
Employer
Supervisor
Address
City
County
State
Zip
Country if not United States
Phone (
)
Occupation
Reason for Leaving
- 4 -
To Mo./Yr.
From Mo./Yr.
Employer
Supervisor
Address
City
County
State
Zip
Country if not United States
Phone (
)
Occupation
Reason for Leaving
To Mo./Yr.
From Mo./Yr.
Employer
Supervisor
Address
City
County
State
Zip
Country if not United States
Phone (
)
Occupation
Reason for Leaving
To Mo./Yr.
From Mo./Yr.
Employer
Supervisor
Address
City
County
State
Zip
Country if not United States
Phone (
)
Occupation
Reason for Leaving
To Mo./Yr.
From Mo./Yr.
Employer
Supervisor
Address
City
County
State
Zip
Country if not United States
Phone (
)
Occupation
Reason for Leaving
Attach another sheet if necessary.
Since the date of the revocation order, have you been terminated, suspended, or allowed
to resign in lieu of termination?
Yes
No
If “yes”, on a separate sheet of paper provide a brief explanation of the circumstances of
each occurrence.
- 5 -