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

Certificate Number

Hidden

Replacement Certificate Number

Hidden

Replacement Certificate Created?

Yes

DWI Intervention Certificate Information

Identification

Secondary Contact

Title