DUI Program - 72-hour Reschedule Request

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.

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 *

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