Please complete this form to submit a request for your personal reinstatement requirements. The following information is required for us to accurately identify your record and respond to you.

Request for Reinstatement Requirements

Allow three business days for a reply. If you require more immediate assistance, contact the Customer Service Unit at 303-205-5613.

Today's Date: Friday, November 20, 2009

*First Name                         Middle Initial  *Last Name                                 
         
                                 
*Date of Birth:
*Month           *Day   *Year
January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925
         
*Social Security Number (Last four digits only)
 
 
Day Time Phone#


*Email Address

 
*Retype Email Address

   
*State of Residency
AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
 
Colorado Driver's License or ID Number (if available)
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  Under penalty of perjury, I attest that I am the person of interest identified above requesting my reinstatement requirements.

I understand that use of this request form for any reason prohibited by law may subject me to civil penalties under federal and state law.

*Required Fields