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Reinstatement Application and HIPAA Authorization Forms

Located on this page are the state applications and forms necessary for a formal reinstatement request. Should you have any further questions, please contact customer service.


Reinstatement Application & HIPAA Authorization
Owner's State of Residence
*Drug/Alcohol
Questionnaire
*Aviation
Questionnaire
*Avocation
Questionnaire
*Foreign Travel
Questionnaire
Florida (pdf)
N/A
Georgia (pdf)
N/A
Indiana (pdf)
Maine (pdf)
Maryland (pdf)
Minnesota (pdf)
Missouri (pdf)
New York (pdf)
Oregon (pdf)
Texas (pdf)
Vermont (pdf)
Virginia (pdf)
Wisconsin (pdf)

*Foreign Travel Questionnaire: Common and State specific foreign travel questionnaires, required if a 'Yes' answer is given for the 'Foreign Travel' question on the Reinstatement app. Note - The Foreign Travel Questionnaire is not required for the states of Florida and Georgia.

*Drug / Alcohol Questionnaire: Common and State specific drug and alcohol questionnaires, required if a 'Yes' answer is given for the 'Drug and Alcohol' question on the Reinstatement app.

*Aviation Questionnaire: Common and State specific Aviation questionnaires, required if a 'Yes' answer is given for the 'Aviation' question on the Reinstatement app.

*Avocation Questionnaire: Common and State specific Avocation questionnaires, required if a 'Yes' answer is given for the 'Foreign Travel' question on the Reinstatement app.

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