Request for IDRP Completion Letter

1. I authorize the Vermont Impaired Driver Rehabilitation Program (IDRP) to disclose my IDRP completion status via letter. *This question is required.

First Name *This question is required.

Last Name *This question is required.

Birth Date (DD/MM/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Email address *This question is required. This question requires a valid email address.

Phone number *This question is required. This question requires a valid number format.

2. I want IDRP to send my completion letter by: *This question is required.

3. Email address This question requires a valid email address.

3. Fax number This question requires a valid number format.

3. Mailing address

Name *This question is required.

Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

3. I authorize the Vermont Impaired Driver Rehabilitation Program (IDRP) to disclose my IDRP completion status to the recipient detailed and by the method chosen. I understand this may disclose that substance use treatment occurred, but the IDRP completion letter will not disclose any diagnosis/es or details of any treatment episode. *This question is required.

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