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Referral Form
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Please complete ALL information below .
Date
*
Date
County or State Requesting Referral
*
Offender/Arrest Information
Name
*
Date of Birth
*
Date of Birth
Address
*
Phone
Arrest Date
*
Arrest Date
Arresting Agency
*
Agency Code
OLN #
*
BAC
*
Services Requested
Request offender be enrolled in Alcohol Highway Safety School
Request offender be scheduled for CRN evaluation
Refer for drug/alcohol assessment if indicated by CRN evaluation
CRN evaluation is attached (attachments may be added below)
Offender completed Alcohol Highway Safety School - enter date below in "comments" section
Offender has failed to complete our Alcohol Highway Safety School due to failure to pay for services
Offender has failed to complete Alcohol Highway Safety School due to failure to respond to scheduled appointments
Offender has failed to complete our Alcohol Highway Safety School due to failure to attend class as scheduled
Did this arrest occur in Pennsylvania?
*
-- Select One --
Yes
No
If the arrest occurred in Pennsylvania, you must attach the Affidavit of Probable Cause filed by the Police by clicking the "attachment" link below.
If none of the answers above describe the services requested, please describe now.
If applicable, enter date offender completed our Alcohol Highway Safety School
If applicable, enter date offender completed our Alcohol Highway Safety School
Please upload any files that are necessary to complete this request.
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