IN THE COURT OF COMMON PLEAS OF ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

No. ___ -SU-___

Appellant

V.

COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF TRANSPORTATION, BUREAU OF DRIVER LICENSING Appellee

APPEAL FROM SUSPENSION/REVOCATION OF OPERATING PRIVILEGES

AND NOW, this ___ day of___, 20___, comes the Appellant, ___, who respectfully avers as follows:

1. Appellant, ___, resides at ___,
2. Adams County, Pennsylvania, 17_____and the telephone number at which he/she can be contacted during normal daytime business hours is (_____) - _____ - _____.
2. Appellant's Pennsylvania Driver License Number is listed on the Confidential Information Form included with this filing.
3. Appelle is Commonwealth of Pennsylvania, Department of Transportation, Bureau of Driver Licensing, hereinafter DOT.
4. Appellant has received notice dated ___ that his/her operating privileges has been suspended (___) revoked (___) by DOT effective ___ for a period of ___ days/months/years (circle one) pursuant to Section ___ of the Pennsylvania Vehicle Code. A copy of said notice is attached hereto and marked as Exhibit "A".