Form 735-6044 - Hardship / Probationary Permit Application printable pdf download

HARDSHIP / PROBATIONARY PERMIT APPLICATION

Mail application and all requirements to: DMV, 1905 LANA AVE NE, SALEM OR 97314

- NOT ISSUED FOR COMMERCIAL (CDL) DRIVING PRIVILEGES -

SECTION 1

▼

DRIVER INFORMATION

▼

DRIVER LICENSE / CUSTOMER NUMBER

DATE OF BIRTH

FULL LEGAL NAME (Print: last, first, middle)

CONTACT PHONE NUMBER

(

)

RESIDENCE ADDRESS (Address will be used to update your driver record/license)

MAILING ADDRESS IF DIFFERENT (Address will be used to update your driver record/license)

No more than 12 hours of driving time allowed per day. You must sign your name at the bottom of this application.

application.

SECTION 2

▼

DRIVING FOR WORK

▼

Must also submit employment verification (see reverse side).

NAME OF EMPLOYER, COMPANY, ETC.

Are you self-employed?

YES

WORKSITE ADDRESS

EMPLOYER PHONE NUMBER

(

)

Circle work days:

MON

TUE

WED

THU

FRI

SAT

SUN

Mileage to work (one-way): ____________

List Work Shifts (specify am/pm):

Do NOT include drive times. DMV will determine and add driving time to your work shifts, depending on mileage listed. Example: If you

note your work shift is 7am-3:30pm, DMV will list your drive times as 6am-7am and 3:30pm-4:30pm.

___________________________________________________________________________________________

Do you drive on the job?

Do you drive employer’s vehicle(s)?

YES*

YES

* If yes, employer letter must verify you are required to drive on the job. List counties driven while on the job (Counties must connect):

___________________________________________________________________________________________

SECTION 3

▼

ALCOHOL and/or DRUG TREATMENT

▼

Driving time for treatment is separate from and not included in the 12-hour driving time limit. Use a separate piece of paper if necessary.

NOTE: Requests for several meetings may be denied due to limited space on the permit. Please note preferred meeting first.

Name and address of meeting:

Circle meeting days:

Time meeting starts and ends:

MON

TUE

WED

THU

FRI

SAT

SUN

Name and address of meeting:

Circle meeting days:

Time meeting starts and ends:

MON

TUE

WED

THU

FRI

SAT

SUN

SECTION 4

▼

COURT RECOMMENDATION

▼

A recommendation from the convicting court is required if you are currently suspended for driving under the influence of intoxicants (DUII),

eluding, reckless driving or misrepresentation of age.

NOTE: The following are NOT convictions for DUII and do NOT require a court recommendation: A Diversion Agreement granted by the court; or a suspension for failing or

refusing to submit to a breath test, blood test, urine test, or a combination thereof under the Implied Consent Law.

Judge’s recommendation per ORS 807.250.

APPROVED

DENIED

(DMV will not issue a permit)

Judge’s Comments: ___________________________________________________________________________________

SIGNATURE OF CONVICTING JUDGE

COURT

DATE

SECTION 5

▼

APPLICANT SIGNATURE

▼

By signing this application, I certify that all documentation and information I provide to DMV is true and correct. I understand it is a crime to knowingly make a

false application for driving privileges. The offense is a Class A misdemeanor and is punishable by jail time, a fine or both. DMV will deny, cancel and/or

suspend my permit or driver license if I make a false statement or present false documentation.

I must notify DMV in writing if information on this application changes. The permit, once issued, constitutes my consent to abide continuously to all

conditions, requirements and restrictions while driving.

DATE

APPLICANT SIGNATURE (Full Legal Name)

735-6044 (2-17)

STK# 300224