DUI Program – 72-hour Reschedule Request

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You may submit this form to request a reschedule. This form must be submitted at least 72 hours prior to your scheduled activity. The fee for a reschedule is $10.00.

Submission of this form does not automatically result in approval of your request. We will email or call you to confirm the reschedule.

If you are human, leave this field blank.

Section 1: Client Information

Full Name: *

Email Address: *

Confirm Email Address: *

Primary Phone Number *

Section 2: Program Location

Identify which Sacramento County Breining Institute DUI Program location you are attending: *

NORTH COUNTY: 8894 Greenback Lane, Orangevale

FOLSOM: 2360 E. Bidwell Street, Suite 107, Folsom

MID-COUNTY: 2775 Cottage Way, Suite 25, Sacramento

SOUTH COUNTY: 3159 Dwight Road, Suite 100, Elk Grove

Section 3: Credit Card and Payment Information

You give permission to and authorize Breining Institute to charge the ten dollar ($10.00) 72-hour Reschedule Request Fee to the following credit card:

Credit Card: *

VISA

MasterCard

Discover

Credit Card Number: *

Full Name on Credit Card: *

Credit Card Expiration Date *

Captcha *

reCAPTCHA is required.

Submit

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