DUI Pre-Registration Forms
Choose File, Print… from your browser menu to print these forms. Each form will print on a separate page. You will need to bring the completed forms and the following items with you in-person in order to complete the registration process:
- Court Order (if convicted).
- Current Picture ID.
- Arrest Affidavit (can be obtained at the Clerk of the Circuit/County Court). Copies must be legible.
- Arrest Citation (copy must be legible).
- Breath/Blood Alcohol Level reading.
Please refer to the Registration Information page you printed, to find the office location nearest you.
At the time of registration you will be scheduled for the appropriate DUI class and evaluation.
Thank You,
Director and Staff of the DUI Program
For further information, please call 407-896-1894.
DUI Program Rules
The Florida Safety Council
Dear Student:
Welcome to the Florida Safety Council DUI Program (FSC). Our program, our Instructors and Evaluators are all certified by the State of Florida Department of Highway Safety and Motor Vehicles (DHSMV) to provide DUI courses for first offenders and multiple offenders who live in Seminole, Orange, Osceola or Brevard Counties. We are a reporting agency to the Courts, Probation Services and DHSMV, Drivers Licenses Bureau. We are required to report attendance or non-attendance. Our goal is to assist you completing the requirements of the DUI Program in order to retain your license or have your license reinstated by the Bureau of Driver License at the end of your revocation period. Please plan to attend since either Court of DHSMV may still require completion; DHSMV may require even if found not guilty, case dismissed; or Court may require even if license is reinstated by DHSMV prior to conviction. The following is a list of student's rules to help you with the process:
- No alcohol, controlled substances or weapons will be allowed in any Florida Safety Council classroom location facility or on the grounds. Portable phones must be turned off and pagers placed on quiet mode.
- No smoking in the building. Food or beverages in the classroom are not permitted. Vending machines are located in the student lounge areas for your convenience in some of our facilities. Ask your instructor for locations.
- Your payment for the DUI Program course is only good for 90 days from the date of registration, according to DHSMV Administrative Rules. If you do not complete all of the DUI Program requirements within the 90 days, you will need to pay the enrollment fee again to re-enroll in the course. All fees payable to FSC are not refundable.
- You MUST be on time for ALL appointments and classes. If you are late for any reason other than good cause such as documented hospitalization; documented incarceration; your own illness (documented by your physician with specific dates); documented death of an immediate family member; or a natural disaster; you will need to pay a reassignment fee and receive a new class schedule. Classes must be attended in order and will begin again with Session 1. Please refer to your class schedule or evaluation appointment paperwork for the fee.
- Evaluation appointments begin on the hour and run on schedule. Each appointment lasts one hour. If you arrive late, the evaluation cannot be done and you will be required to pay a rescheduling fee. Please refer to your evaluation appointment paperwork for the fee schedule.
- Classes begin on schedule, and you WILL NOT be allowed into the classroom if you arrive after the roll class has been taken. You will have to pay the amount listed on your registration form to reschedule your class.
- If you come to your classes or evaluation after consuming alcohol, abusing prescription medication or another controlled substance, or if the odor of alcohol is present on your person, you will be asked to leave. If you are asked to leave, you will pay 100% of the enrollment fees to reenroll. FSC staff may perform periodic breath tests. You may also be referred for urinalysis at your expense if recommended by a FSC certified Evaluator or Instructor.
- If you are disruptive in class or during the evaluation appointment, you will be asked to leave. If you are asked to leave, you will pay 100% of the enrollment fees to reenroll. Disruptive behavior includes in person or over the phone.
- If you need to change your evaluation appointment or class schedule, you must contact this office, in person FIVE (5) business days prior to the date assigned or first class session, to sign new paperwork. You will be allowed 2 reassignments within 90 days at no fee. If less than 5 business days prior to reschedule date, a reassignment fee will be charged.
- If you wish to transfer to another In-State or Out-State DUI Program, there is a $25.00 cash transfer fee and a DHSMV form to be signed to the new Program. You must contact the new Program, and the new Program must send us updates.
- Children and guests ARE NOT allowed during classes, evaluation sessions or during the registration process. Children ARE NOT to be left without adult supervision in any part of the building.
- Appropriate dress is required. Appropriate behavior is expected.
- If you have registered for the wrong DUI program, by withholding information on previous DUI charges or DUI program attendance and a record check by FSC or DHSMV reveals the error, you will be required to pay for the correct DUI program. The fees already paid for the incorrect program are forfeited and will not transfer.
- Completion certificates are not issued until the evaluation and classes are completed.
- OTHER FEES:
$15.00 Treatment Agency Transfer Fee, if you are referred and wish to change agencies.
$ 5.00 Duplicate Certificate fee, if you need to replace your DUI Completion Certificate.
We hope this information will help you with successful completion of the DUI Program.
Staff of the DUI Program
| CLIENT SIGNATURE | DATE |
FSC000405 Rev. 8/09
Student Conduct
The Florida Safety Council
The Department of Highway Safety & Motor Vehicles Administrative Rules allow the DUI Program to:
- Dis-Enroll or Refuse to Enroll any individual who refuses to complete the folder information, answer the testing instrument, or refuses to actively participate in the evaluation appointment or the class sessions.
The Department of Highway Safety & Motor Vehicles Administrative Rules allow the DUI Program to:
- Dis-Enroll or Refuse to Enroll any individual who is DISRUPTIVE or UNWILLING to COMPLY with the rules and procedures of the Program. DISRUPTIVE BEHAVIOR is defined as using abusive, threatening language or gestures; shouting or using profanity at staff or at other students; or behavior which would be unacceptable to the Court. Behavior includes actions / statements in person, by telephone or by mail.
- DISRUPTIVE BEHAVIOR may result in a call to 911 for escort from the premises, and possibly a No Trespass Order. A report of the Incident will be sent to the Court and/or Probation.
These guidelines were established to provide all students with a positive and safe learning environment.
| STUDENT SIGNATURE | DATE |
FSC000670 Rev. 8/09
CONFIDENTIAL INFORMATION
The Florida Safety Council
This paperwork and your attendance at the Florida Safety Council DUI Program is confidential and protected under State and Federal Confidentiality Laws.
This information has been disclosed to you from your records, protected by Federal confidentiality rules—Chapter 42 of the Code of Federal Regulations, Part 2 [42 CFR Part 2]. The Federal rules prohibit the DUI Program from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains (you the Student), or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information in NOT sufficient for this purpose. The Federal rules restrict any use of the alcohol or drug abuse patient.
Family members and attorneys cannot handle any aspects of this DUI Program attendance for you. This is to protect your privacy.
You will need to come in to any of the office locations in person, Monday through Friday in Orlando, Longwood, Kissimmee, Melbourne, or Merritt Island. Call ahead to determine if an office will be open from 8am - 12pm on Saturday for registration. Please arrive at least 2 hours before the close of business in order to complete the registration process. If you cannot physically come in, please send your question in writing to the address listed on your registration paperwork. Please plan on 5 to 7 business days for a written response to arrive.
| STUDENT SIGNATURE | DATE |
FSC000671 Rev. 12/03
DUI PROGRAM PRE-REGISTRATION FORM
PLEASE COMPLETE THE FOLLOWING FORM
Name: ___________________________________________________________________________________________________
First
Middle
Last
Residence Address: _______________________________________________________________________________________
Street Address
Apt.#
| _____________________________________________________________________
City State Zip Code County |
Emergency Phone#: (_____)______ - _______ Emergency Contanct Name:____________________ Relationship: _________________
Drivers License #: _____________________________ State: _________ Social Security #: _________- ________ - __________
Date of Birth: ____/____/____ Age: _____ Race: ________________ Sex: M_____ F_______ Marital Status: _____________________
Work Phone: (_____)______-_______ Profession: ________________________Place of Employment: ____________________________
Number of Years in School: __________ Main Language: _______________ How did you hear of our service?: ____________________
Citation#: _________________ Charge: ________________________ Arrest Date: ____/____/____ County & State of Arrest: ________
Court Date: ____/____/____ County: __________________ Judge: ______________________ Probation Officer: ___________________
Number of previous DUI arrests: __________ and number of Reckless Driving (Alcohol/Substance Involvement) arrests: ______________
REASON FOR ENROLLING IN THE DUI COUNTERATTACK PROGRAM PLEASE CHECK APPROPRIATE LEVEL—Based upon Lifetime history in ALL states/countries—not just Florida:
________________________________________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Ignition Interlock Device Violations:
________________________________________________________________________________________________________
PREVIOUS ATTENDANCE(S) AT A DUI PROGRAM:
Reason Attended: ___________________________________________ Dates of Attendance: ___________________________
Location (City/State): ______________________________________________________________________________________
*** Registration Fees are set by DHSMV Administrative Rules and are not Refundable ***
NOTE: IF THROUGH A RECORDS CHECK BY THE DUI PROGRAM, BY THE COURT, OR BY THE DRIVER LICENSE BUREAU, IT’S DETERMINED THAT YOU HAVE HAD A PRIOR DUI, DWI, OUI, OWI, DWAI, RECKLESS DRIVING ARREST- ALCOHOL OR DRUG RELATED; OR YOU HAVE HAD A PRIOR LICENSE SUSPENSION FOR ALCOHOL OR FOR REFUSAL; OR YOU HAVE HAD A PRIOR DUI PROGRAM ATTENDANCE ANYWHERE, IN YOUR LIFETIME, ON A FLORIDA OR ON ANY OTHER STATE LICENSE RECORD, THE MONEY PAID WILL BE FORFEITED AND YOU WILL BE REQUIRED TO PAY THE FEE FOR THE APPROPRIATE CLASS. MONEY PAID AND CLASS TIME ATTENDED WILL NOT TRANSFER / NOR WILL IT BE CREDITED. THE COMPLETE, OFFICIAL LIFETIME FLORIDA DRIVING RECORD MUST BE PROVIDED BY THE STUDENT AT TIME OF ENROLLMENT. IF THE MVR IS SUPPLIED BY THE STUDENT, THE DRIVING RECORD MUST BE AN OFFICIAL DHSMV-BASED PRINTOUT, LESS THAN 15 DAYS OLD, AND REFLECT A LIFETIME RECORD. IF ANOTHER STATE ISSUED THE DRIVER LICENSE, THE LIFETIME RECORD FROM THAT STATE WILL NEED TO BE PRESENTED.
I, the undersigned, confirm that the information provided by me above is true and correct AND I understand fees are NOT REFUNDABLE.
SIGNED: _______________________________________________________________
DATE: _________________________
Created for completion of DHSMV Form 77004 (Rev. 1/7/97) [Part
1 of Client Data Information] FSC
From 000189 (Rev 10/09)
DUI COUNTERATTACK PROGRAM
The Florida Safety Council
ORANGE COUNTY
Florida Safety Council427 N. Primrose Drive Orlando FL 32803 (407) 896-1894 |
SEMINOLE COUNTY
Florida Safety Council[In Times Square Plaza] 851 E. SR 434, Suite 190 Longwood FL 32750 (407) 831-7200 Registration: M-F: 8am to 3pm Office Open: M-F: 8am to 5pm |
OSCEOLA COUNTY
Florida Safety Council[In La Mirada Plaza] 3501 W. Vine Street 2nd Floor Suite 200 Kissimmee, FL 34741 (407) 846-2555 Registration: M-F: 8am to 3pm Office Open: M-F: 8am to 5pm |
BREVARD COUNTY
Florida Safety Council
Registration: M-F: 8am to 3pm Office Open: M-F: 8am to 5pm |
BREVARD COUNTY
Florida Safety Council2nd floor] 250 N. Courtenay Parkway Ste 201 Merritt Island, FL 32953 (321) 631-2347 Registration: M-F: 8am to 3pm Office Open: M-F: 8am to 5pm |
|
REGISTRATION TAKES APPROXIMATELY TWO HOURS, SO PLEASE PLAN AHEAD
TUITION FEES EFFECTIVE OCT 1ST 2009: **
| Level I – [12 Hours] | $233.00* | No Prior DUI, Reckless, Suspension or Revocation in Lifetime. |
| Level II – [21 Hours] | $363.00* | Has had any prior DUI, Reckless, Suspension or Revocation in Lifetime |
Fees are payable in cash, money order, or credit card. Official Lifetime Driving Record must be provided by student. On-line Registrations will require a $ 7.00 processing and postage fee, in addition to tuition.
EVALUATION LOCATIONS:
Evaluations are provided in all office locations. Daytime and evening evaluation appointments are available.
REASSIGNMENT FEE:
| CLASSES | 1st | 2nd | 3rd or Subsequent | After 90 Days |
| Level I | $40.00 | $ 75.00 | $153.00 | $233.00 |
| Level II | $60.00 | $120.00 | $238.00 | $363.00 |
| EVALUATIONS | 1st | 2nd or Subsequent | After 90 Days | |
| Level I | $75.00 | $153.00 | $233.00 | |
| Level II | $75.00 | $153.00 | $363.00 |
DOCUMENTATION REQUIRED WHEN ENROLLING IN DUI PROGRAM:
- Driver License Number
- Arrest Affidavit (Arrest Report or Crash Report) - must be a legible copy
- Citation (Ticket) - must be a legible copy
- Results of Breath or Blood test, Urinalysis results, Refusal Slip
- Court Disposition or Court Order, if already appeared in Court or convicted
- Picture ID - such as a current Florida Identification Card, valid Passport (NOT EXPIRED)
** Tuition Fees are approved and Reassignment Fees are set by the Department of Highway Safety and Motor Vehicles and include the $15.00 DUI State Assessment Fee. Tuition Fees are subject to change at the direction of the Department of Highway Safety & Motor Vehicles. Tuition fee is valid for only 90 days from date of enrollment and is not refundable. After 90 days the full tuition is paid again and both evaluation and classes are started over again. Classes always start over with class session 1.
If the student arrives at a class session or the evaluation appointment under the influence of alcohol or other drugs, the full fee will be paid again. If student’s behavior is disruptive or threatening, he/she may be dis-enrolled. Tuition Fees are not refundable.
The complete, official Lifetime Florida Driving Record must be provided by the Student at time of enrollment. If the MVR is supplied by the student, the Driving Record must be an official DHSMV-based printout, less than 15 days old, and reflect a lifetime record. If another state issued the Driver License, the lifetime record from that state will need to be presented.

