Form Dr 2643 PDF Details

Form Dr 2643, also known as the Uniform Hazardous Waste Manifest, is a form used to track hazardous waste from cradle to grave. It was created to help ensure that hazardous waste is handled and disposed of in accordance with regulations set by the Environmental Protection Agency (EPA). Use of this form is mandatory for all handlers and disposers of hazardous waste. In this blog post, we will discuss what information is required on Form Dr 2643, and how to complete it accurately. We'll also highlight some common mistakes made on this form, and provide tips for avoiding them. Let's get started!

QuestionAnswer
Form NameForm Dr 2643
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesaffidavit enrollment level, colorado form enrollment, dr2643, dr2643 form

Form Preview Example

DR 2643 (03/10/15)

COLORADO DEPARTMENT OF REVENUE

Division Of Motor Vehicles

Driver Control Section, Room 164

Phone: (303) 205-5792

www.colorado.gov/revenue

Afidavit of Enrollment

Level II Drug and Alcohol Education and Treatment

This Section to be Completed and Returned to The DMV Driver Control Section

Name

Date of Birth

Colorado PIN

Date of Admission

Agency Name

Agency ID

Track Assigned

Estimated Date of Completion

Signature of Authorized Staff Member

Date

Agency’s Phone Number

1.As a condition for the reinstatement of driving privileges, I must complete a Level II alcohol and drug education and treatment program. I understand that the agency providing this service is required to report any noncompliance with the terms of such program and that a report of noncompliance may result in cancellation of my driver’s license and denial to reapply until evidence of successful completion of a licensed education and treatment program is provided and any other reinstatement requirements are met.

2.If notice of noncompliance is received by the Division of Motor Vehicles - Driver Control Section from the agency listed above, one of the following documents must also be received within 20 days.

•Notice from that agency that the terms and conditions of the program are now being met.

•A discharge referral summary indicating successful completion of a Level II education and treatment program from the agency listed above.

•A new Afidavit of Enrollment indicating admission to another licensed Level II program.

Failure to provide these documents will result in cancellation and denial of driving privilege.

Signature of Applicant

Date

This Section to be Retained in The Records of The Agency Providing

Level II Education and Treatment Program

Client Name

Track Assigned

 

Date of Birth

Estimated Date of Completion

Colorado PIN

 

 

Pursuant to §42-2-144, C.R.S. the following information must be forwarded to the Division of Motor Vehicles, Driver Control Section regarding this client.

•Report of noncompliance with the terms and conditions of this program - within 5 days of occurrence.

•Report of completion of program with a discharge referral summary showing: admission date, discharge date, and indicating successful completion of track assigned - not more than 20 days following completion date.

•Report of compliance with terms and conditions of program - quarterly.

How to Edit Form Dr 2643 Online for Free

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Step 1: First, access the pdf editor by clicking the "Get Form Button" at the top of this site.

Step 2: The editor will give you the opportunity to customize your PDF form in many different ways. Change it with customized text, adjust original content, and include a signature - all at your disposal!

As for the fields of this specific PDF, this is what you should do:

1. The affidavit enrollment level needs particular information to be inserted. Make certain the subsequent blank fields are finalized:

Completing section 1 in colorado dr 2643 form

2. Immediately after the previous part is completed, go on to type in the relevant information in these - Failure to provide these documents, Signature of Applicant, Date, This Section to be Retained in The, Level II Education and Treatment, Client Name, Date of Birth, Track Assigned, Estimated Date of Completion, Colorado PIN, Pursuant to CRS the following, Report of noncompliance with the, Report of completion of program, and indicating successful, and Report of compliance with terms.

Filling out part 2 in colorado dr 2643 form

You can potentially make an error while filling in your and indicating successful, therefore ensure that you reread it prior to deciding to finalize the form.

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