License Reinstatement Application

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***You MUST complete EVERY line. Write N/A on any line that does not apply to you. Incomplete applications will
not be processed. False information will result in rejection of your application. Call 641-421-3111 with questions.***
Please correct the field(s) marked in red below:

I want to... (select all that apply)
 *
I want to... (select all that apply)

Applicant Information (required)

Name
 *
Name
Address
 *
Address
How long have you lived at your current address?
 *
Email Address
Personal Identification Information
 *
Personal Identification Information
Phone
 *
Phone

Employment Information (required)

I am... (check only one) 
 *
I am... (check only one)
ONLY complete if unemployed*
ONLY complete if employed
 *
ONLY complete if employed

Household Information (required)

Spouse (if applicable)
Spouse (if applicable)
Other Adult (if applicable)
Other Adult (if applicable)
Financial Assistance Received (required)
Please complete the blanks for any assistance you receive:
Please complete the blanks for any assistance you receive:
Other Information (required)
Criminal History:
Criminal History:

I do have criminal charges pending... (Please provide the information below.)

I am on probation or parole... (Please provide the information below.)

I am on probation or parole... (Please provide the information below.)
The following individual can confirm my ability and willingness to participate in this program and make payments. If I am unable to be contacted, I understand the Cerro Gordo County Attorney's Office may attempt to reach me via this individual.
The following individual can confirm my ability and willingness to participate in this program and make payments. If I am unable to be contacted, I understand the Cerro Gordo County Attorney's Office may attempt to reach me via this individual.

Applicant Statement (optional)

I would like to submit the following additional information or special circumstances in support of my application:
I have read and completed all fields that apply to me. I submit the above information and promise that it is true and correct. I understand admission to the program is not guaranteed and is based on the discretion of the Cerro Gordo County Attorney's Office.
I have read and completed all fields that apply to me. I submit the above information and promise that it is true and correct. I understand admission to the program is not guaranteed and is based on the discretion of the Cerro Gordo County Attorney's Office.