Occupational License Case Information Sheet
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2121903 Filing Information Sheet
C
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. ________________
AUSE
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C
HE
TATE OF
EXAS
N
HE
OUNTY
RIMINAL
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________________________________________, §
D
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O
H
C
, T
EFENDANT
F
ARRIS
OUNTY
EXAS
O
L
C
I
S
CCUPATIONAL
ICENSE
ASE
NFORMATION
HEET
You must complete this form and a file copy with every original petition. You must also attach a copy of
this form to every original petition served. This information does not constitute a discovery request,
response, or supplementation, and is not admissible at trial.
On the date of the offense, Petitioner was under 21 years of age .
On the date of the offense, Petitioner was over 21 years of age.
Administrative License Suspension for :
failing the breath or blood test
refusing to give a specimen of breath or blood.
Automatic Suspension after conviction or being placed on community supervision for:
Criminally Negligent Homicide
Fraudulent Government Records
-- Prosecuted Under T
.
EX
Drug Offense
P
C
§ 37.10
ENAL
ODE
DWI (Alcohol)
False/Fictitious Driver’s License
DWI (Drug)
or DPS I.D. Card
Driving While Commercial
Criminal Mischief / Graffiti
License Disqualified
Intoxication Assault With A
DWLI
Motor Vehicle
Evading Arrest
Intoxication Manslaughter
Failure To Stop And Render Aid
Racing
False/Fictitious Motor Vehicle
Other ___________________
License Plate, Registration
___________________________
Insignia, Or Safety Inspection
Certificates
The case was heard in County Crim. Court at Law No. ___.
The case was heard in _____District Court
The offense occurred in __________________ County.
The license was suspended on ___________________.
Name of individual filing cover sheet:
Attorney or pro se (signature)
Printed name
Bar card (if applicable)
Telephone number
Address
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