Driver’s License Recovery Screening

Driver’s License Recovery Program Screening Acknowledgment

BY COMPLETING THIS SCREENING FORM, YOU AGREE TO THE FOLLOWING:

  • I give permission to YWCA Madison staff to provide information such as my social security number, name, address, and other information to government agencies in order to achieve desired goals.
  • I certify that the information provided here is true to the best of my knowledge.
  • I understand that I need to follow through with all court dates, judgments, and other activities required by the court or YWCA Madison staff. Failure to do so will result in the termination of services.
  • I understand that enrollment in this program is a one-time opportunity, and if I am enrolled, I will not be eligible for enrollment in the future.

Driver's License Recovery Screening

  • Date Format: DD slash MM slash YYYY
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  • Enter as written with (-)
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  • If your driver's license has been suspended due to no-payment of fines.
  • If your driver's license was suspended for other reasons, not states above.