DWI Intervention Certificate Form - Education Resource of Texas

DWI Intervention Certificate Information

"*" indicates required fields

The information you enter below will be used on your certificate of completion and will be used to mail your certificate to you.

Name*

Enter your legal name, including middle initial, as it appears on your government-issued ID.

Email*

Date of Birth*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Do you have a Cause Number or Case Number?*

Yes

Cause Number or Case Number*

This may contain letters and numbers. If you have more than one cause/case number, list only one here. If you cannot find this number, put N/A. You may also obtain this number by asking your lawyer, probation/parole officer, or the county clerk in the county where you were arrested.

Have you been convicted?*

Yes

County of Conviction*

Identification

Type of ID*

Select one type of ID from the choices below.

State of Issue*

Country of Issue*

Driver License, Personal ID, or Passport Number*

Social Security Number*

Secondary Contact

If you fill out the contact information below, we will send a copy of your certificate to your lawyer, parole, or probation officer.

Contact Type

Name

First Last

Verify Information*

I have verified that all information above is correct.

Hidden

Course Date

Hidden

Certificate Number

Hidden

Replacement Certificate Number

Hidden

Replacement Certificate Created?

Yes

DWI Intervention Certificate Information

Identification

Secondary Contact

Title