Form Center

2. First Name*
3. Last Name*
5. Sentencing Court*
   Please indicate your sentencing Court.
6. County of Conviction*
   Please indicate the county of conviction
7. Sentencing Judge
   Please indicate the name of the sentencing Judge.
9. Are you mandated to attend an Impact Panel?*
   -- Select One --YesNo
10. 2019 DWI Impact Panel Dates*
    -- Select One --January 14, 2019 Men's PanelMarch 4, 2019 Women's PanelApril 1, 2019 Men's PanelJune 10, 2019 Men's PanelJuly 15, 2019 Women's PanelSeptember 09, 2019 Men's PanelOctober 07, 2019 Women's PanelNovember 04, 2019 Men's Panel

    Please choose the date you wish to attend.
12. LOCATION: Ontario County Safety Training Facility, 2914 County Road 48, Canandaigua, NY 14424
13. TIME: Registration begins at 6:15pm and ends at 6:55pm. Impact Panel starts at 7:00pm and ends at 8:30pm. NO LATE ENTRIES ALLOWED!
15. A $40.00 FEE (EFFECTIVE 04/01/18) IS REQUIRED AND WILL BE COLLECTED DURING REGISTRATION. CREDIT CARD, CASH, MONEY ORDER MADE PAYABLE TO ONTARIO COUNTY WILL BE ACCEPTED. ONLINE CREDIT CARD PAYMENT CAN BE MADE PRIOR TO THE PANEL. THERE WILL BE NO REFUNDS IF YOU ARE DIRECTED TO LEAVE.
17. • DO NOT DRIVE TO THE VIP UNLESS YOU POSSES A VALID DRIVER’S LICENSE. A DWI IMPACT PANEL IS NOT COVERED UNDER A CONDITIONAL/RESTRICTED LICENSE. • DRINKING OR ILLICIT DRUG USE PRIOR TO ATTENDANCE IS STRICTLY PROHIBITED. ANYONE FOUND TO BE UNDER THE INFLUENCE OF DRUGS/ALCOHOL WILL NOT BE ALLOWED TO ATTEND. • LATECOMERS WILL NOT BE ADMITTED. YOU MUST ARRIVE BEFORE 6:55PM. • ONCE INSIDE THE PANEL, CELL/SMART PHONES ARE NOT ALLOWED. ANYONE FOUND TO BE IN POSSESSION OF/USING A CELLPHONE WILL BE DIRECTED TO LEAVE AND WILL BE RETURNED TO COURT. • NO FOOD OR BEVERAGES ARE ALLOWED INSIDE THE PANEL. • IF YOU FAIL TO COMPLY WITH DIRECTIVES GIVEN BY THE STOP-DWI ADMINISTRATOR AT THE START OF THE PANEL, YOU MAY BE DIRECTED TO LEAVE AND YOUR SENTENCING COURT WILL BE NOTIFIED.
19. Your Email:*
    Confirmation and additional information will be sent to your email address.
20. Today's Date*
    Today's Date
22. I ACKNOWLEDGE THE CONDITIONS OF ATTENDANCE AT A DWI IMPACT PANEL. I AM FULLY AWARE OF THE CONDITIONS IMPOSED UPON ME.
24. Signature*
    Please type your name acknowledging that you have read the terms and conditions.
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

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