OSAH FORM 1
OSAH FORM 1This form is available online at or by telephone request at (404) 657-2800.OSAH USE ONLY:AGENCYDDSCASE TYPEDOCKET NUMBERCOUNTYJUDGEUse For MISCELLANEOUS DDS CASE REFERRALS SELECT ONLY ONE TYPE OF CASESELECT ONE CASE TYPELICENSE ISSUESPERMIT HOLDER/APPLICANT APPEALSDRIVER TRAINING AND IMPROVEMENT APPEALS FORMCHECKBOX FTAFailure to Appear O.C.G.A. § 40-5-56 FORMCHECKBOX HVPLHabitual Violator Probationary License O.C.G.A. § 40-5-58 FORMCHECKBOX LDPLimited Driving Permit O.C.G.A. § 40-5-64 FORMCHECKBOX RCLRestricted Commercial License FORMCHECKBOX SVSchool Violation O.C.G.A. § 40-5-22 FORMCHECKBOX MVSRAMotor Vehicle Safety Responsibility Act O.C.G.A. § 40-9-3 FORMCHECKBOX MEDMedical Revocation O.C.G.A. § 40-5-59 FORMCHECKBOX IIDLDPIgnition Interlock Device Permit Revocation O.C.G.A. § 42-8-112 FORMCHECKBOX CDLACommercial Driver’s License Application O.C.G.A. § 40-8-92) FORMCHECKBOX CDLCCommercial Driver’s License Cancellation O.C.G.A. § FORMCHECKBOX LCILimousine Chauffeur Permit IssuesO.C.G.A. § 46-7-85.13 FORMCHECKBOX DUIRISKDUI Risk Reduction FORMCHECKBOX CDLSTCommercial Driver’s License Skill Testing (3rd Party) O.C.G.A. § 40-5-147(a)(2) FORMCHECKBOX DIBOND bonding Requirement for Risk Reduction O.C.G.A. § 40-5-80(2) FORMCHECKBOX LDTSILicense for Driver Training School Instructors O.C.G.A. § 43-13-7 OTHER APPEALS: FORMCHECKBOX OTHER NON-AGENCY PARTY: For OSAH CLERK “Permit Holder/Applicant.” “School or Instructor,” or “Petitioner”NAME FORMTEXT ?????TEL #: FORMTEXT ?????FAX #: FORMTEXT ?????CURRENT ADDRESS INCLUDING ZIP CODE: FORMTEXT ?????PERMIT, LICENSE OR OTHER AGENCY REFERENCE NUMBEREMAIL: FORMTEXT ?????ATTORNEY FOR NON-AGENCY PARTYHEARING REQUEST FILED BY: □NON-AGENCY PARTY □NON-AGENCY PARTY’S ATTORNEYONLY INDICATE AN ATTORNEY IF THE ATTORNEY AND NOT THE NON-AGENCY PARTY HAD REQUESTED THE HEARING. A CLIENT’S DESIGNATION OF AN ATTORNEY DOES NOT CONSTITUTE AN ENTRY OF APPEARANCE FOR THE ATTORNEY.NAME: FORMTEXT ?????TEL #: FORMTEXT ?????FAX #: FORMTEXT ?????CURRENT ADDRESS INCLUDING ZIP CODE: FORMTEXT ?????GEORGIA BAR #: FORMTEXT ?????EMAIL: FORMTEXT ?????DDS OR DDS DESIGNATED AGENCY REPRESENTATIVENAME: FORMTEXT ?????TEL #: FORMTEXT ?????FAX #: FORMTEXT ?????ADDRESS INCLUDING ZIP CODE: FORMTEXT ?????DESIGNATED COUNSEL’S GEORGIA BAR #: FORMTEXT ?????EMAIL: FORMTEXT ?????DESIGNATED COUNSEL: FORMTEXT ?????TEL #: FORMTEXT ?????FAX #: FORMTEXT ?????DOCUMENTS ATTACHED□Correspondence requesting hearing□Notification from DDS of adverse action□Other, please specify ____________________________________ ................
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