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the above listed email, fax number, or mailing (Arizona Department of Transportation)

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To request a hearing, please complete the following form and send to the Executive Hearing Office by email, fax, or mail at
the above listed email, fax number, or mailing address. Please include a copy of any paperwork or notices you have
received in connection with this matter. If you wish to be notified of requests or motions made by
other participants of
record in this matter, you must provide a valid email address below. If you have any questions or you wish to check the
status of your hearing request, you may contact the Executive Hearing Office at 602-712-7737. Thank you.
Name (first, middle, last, suffix)
Case Number
Mailing Address
City
State
Zip
Date of Birth
Driver License Number
Home Phone
( )
Work Phone
( )
( )
Reason For Request
Signature
Date
HEARING REQUEST
40-5008 R10/16
azdot.gov
Mail Drop 507M
Executive Hearing Office
Arizona Department of Transportation
PO Box 2100
Phoenix AZ 85001-2100
hearingoffice@azdot.gov
Tele: 602-712-7737
Fax: 602-241-1624
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Completed 29 May 2021

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