Referral Form

2. Please complete ALL information below .

4. Date*
   Date

5. County or State Requesting Referral*

9. Offender/Arrest Information

11. Name*

12. Date of Birth*
    Date of Birth

14. Address*

15. Phone

17. Arrest Date*
    Arrest Date

18. Arresting Agency*

19. Agency Code

21. OLN #*

22. BAC*

24. Services Requested

    1. Request offender be enrolled in Alcohol Highway Safety School
    2. Request offender be scheduled for CRN evaluation
    3. Refer for drug/alcohol assessment if indicated by CRN evaluation
    4. CRN evaluation is attached (attachments may be added below)
    5. Offender completed Alcohol Highway Safety School - enter date below in "comments" section
    6. Offender has failed to complete our Alcohol Highway Safety School due to failure to pay for services
    7. Offender has failed to complete Alcohol Highway Safety School due to failure to respond to scheduled appointments
    8. Offender has failed to complete our Alcohol Highway Safety School due to failure to attend class as scheduled

26. Did this arrest occur in Pennsylvania?*
    -- Select One --YesNo

27. If the arrest occurred in Pennsylvania, you must attach the Affidavit of Probable Cause filed by the Police by clicking the "attachment" link below.

29. If none of the answers above describe the services requested, please describe now.

31. If applicable, enter date offender completed our Alcohol Highway Safety School
    If applicable, enter date offender completed our Alcohol Highway Safety School

33. Please upload any files that are necessary to complete this request.

35. Comments

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field