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Get CO DR 2643 2015-2021

A new Affidavit of Enrollment indicating admission to another licensed Level II program. Failure to provide these documents will result in cancellation and denial of driving privilege. Colorado. gov/revenue Affidavit of Enrollment Level II Drug and Alcohol Education and Treatment This Section to be Completed and Returned to The DMV Driver Control Section Name Date of Birth Colorado PIN Date of Admission Agency Name Agency ID Track Assigned Estimated Date of Completion Signature of Authorized Staff Member Date Agency s Phone Number 1. DR 2643 03/10/15 COLORADO DEPARTMENT OF REVENUE Division Of Motor Vehicles Driver Control Section Room 164 Phone 303 205-5792 www. As a condition for the reinstatement of driving privileges I must complete a Level II alcohol and drug education and treatment program* I understand that the agency providing this service is required to report any noncompliance with the terms of such program and that a report of noncompliance may result in cancellation of my driver s license and denial to reapply until evidence of successful completion of a licensed education and treatment program is provided and any other reinstatement requirements are met. 2. If notice of noncompliance is received by the Division of Motor Vehicles - Driver Control Section from the agency listed above one of the following documents must also be received within 20 days. Notice from that agency that the terms and conditions of the program are now being met. A discharge referral summary indicating successful completion of a Level II education and treatment program from the agency listed above. Signature of Applicant Client Name Level II Education and Treatment Program Pursuant to 42-2-144 C. R*S* the following information must be forwarded to the Division of Motor Vehicles Driver Control Section regarding this client. Report of noncompliance with the terms and conditions of this program - within 5 days of occurrence. Report of completion of program with a discharge referral summary showing admission date discharge date and indicating successful completion of track assigned - not more than 20 days following completion date. As a condition for the reinstatement of driving privileges I must complete a Level II alcohol and drug education and treatment program* I understand that the agency providing this service is required to report any noncompliance with the terms of such program and that a report of noncompliance may result in cancellation of my driver s license and denial to reapply until evidence of successful completion of a licensed education and treatment program is provided and any other reinstatement requirements are met. 2. If notice of noncompliance is received by the Division of Motor Vehicles - Driver Control Section from the agency listed above one of the following documents must also be received within 20 days. 2. If notice of noncompliance is received by the Division of Motor Vehicles - Driver Control Section from the agency listed above one of the following documents must also be received within 20 days. Notice from that agency that the terms and conditions of the program are now being met. A discharge referral summary indicating successful completion of a Level II education and treatment program from the agency listed above. .

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