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If your driving privilege has been revoked or disqualified under the Implied Consent Law (Minnesota Statutes, sections
169A.50 -.53), you are entitled to a review of the order by the Commissioner of Public Safety.
Completing this form is the only means to advise the Commissioner of your version of the facts of the incident. It is
important that you complete each item and sign this form so that your request for administrative review is fully
considered.
Once received, the commissioner’s designee will undertake a full review of the facts surrounding the order of revocation
or disqualification, based upon this form and all other records in possession of the Department of Public Safety relating
to this incident.
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This review will not affect pending or future court actions. All of your rights to seek court review of the revocation or
disqualification are preserved, whether or not you request administrative review.
You will be notified by mail of the results of the review within fifteen (15) days after receipt. You may appear in person
during normal business hours to discuss any driver’s license matter with a driver evaluator. In some cases, however, this
could result in a delay beyond the fifteen days within which a written review can be completed.
You may call (651) 296-8599 for information.
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Date of Incident (mm/dd/yy)
1. A peace officer must be able to state a reason for stopping a motor vehicle. In this case:
2. A peace officer must have probable cause to believe that a person was under the influence of alcohol or a
controlled substance while driving, operating or in physical control of a motor vehicle before a request for an
alcohol/controlled substance test of the driver’s blood, breath, or urine can be made.
3. Before being requested to submit to an alcohol/controlled substance test of the driver’s blood, breath, or urine, a
driver is advised by the peace officer of certain rights and facts. These rights are usually read from a printed form.
I don’t remember being stopped.
I was not stopped for a valid reason because:
I agree that I was stopped for a valid reason.
I agree that the peace officer had probable cause to believe that I was under the influence of alcohol or a controlled
substance.
I do not think that the peace officer had probable cause to believe that I was under the influence because:
The peace officer read the form and advised me of my rights and responsibilities.
I don’t recall whether or not I was given the required advice.
The peace officer failed to advise me as follows:
PS31122-09 (07/13)
Request for Administrative Review
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
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Bring or mail this completed application to Driver and Vehicle Services, 445 Minnesota Street, St. Paul,
Minnesota 55101-5170. You may also fax to (651) 282-2463. Please print or type. Use additional sheets or attach
documents if necessary.
