Fillable Form Dr-500-001 - Restricted Driver License Application printable pdf download

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Restricted Driver License Application

For validation only 106-040-254-0005

Use this form to apply for a temporary restricted driver license if your driving

privilege in Washington is currently suspended or revoked. To apply, take this

completed application and a $100 nonrefundable fee to any driver licensing

office or mail your application and a check or money order payable to the

Department of Licensing to:

Restricted License

Restricted license fee __________ Date received ___________

Department of Licensing

LSR initials __________________ Office no._______________

PO Box 3907

Seattle, WA 98124-3907

PRINT OR TYPE Name (Last, First, Middle initial)

Driver license number

State /Jurisdiction

Date of birth

(Area code) Daytime telephone

Delivery information – Email or (Area code) Fax no.

How would you like your license sent to you? (Choose one)

US mail to address on file

Fax

Eligibility / Restrictions

• We will determine what type of temporary restricted license you qualify for based on our evaluation of your driving record.

• Any restricted license issued will only be valid within the state of Washington and cannot be used to operate a commercial

motor vehicle.

• We may also restrict where and when you can drive.

• Your suspension / revocation cannot be for a minor in possession, intermediate license violations, failure to pay child

support, fraud, violation of court-ordered probation, medical or vision reasons, habitual traffic offender status, failure to

enter into or comply with a required alcohol / drug treatment program, or vehicular assault or homicide (except under

certain conditions).

• You must be licensed to operate a motor vehicle. If you are not currently licensed, you must apply and qualify for a

Washington license, which may include knowledge and skills tests.

Required documentation

• Proof of financial responsibility – the most common method is by filing a form called an SR-22. You can get one from most

automobile insurance agents.

• If you are suspended for an alcohol or drug-related offense, contact an ignition interlock company that installs Washington

certified devices. They will send us proof of installation.

If your employment requires you to drive a vehicle during working hours that is owned, leased, rented, or the temporary

responsibility of your employer, it may be exempt. You must carry a signed Employer Declaration form (DR-500-025). This

form is available at

If you are indigent, you may be eligible for assistance with costs of ignition interlock device installation, removal, and leasing.

To apply, submit an Ignition Interlock Device Financial Worksheet (DR-500-024) located at

We must receive proof of the SR-22 insurance and any other required documentation within 30 days of receiving

this application. If not, you must submit a new application and another $100 fee.

Keeping your restricted license

Your restricted driver license will be cancelled if any of the following occurs:

• You are convicted of violating the restrictions.

• Your driving privilege is suspended or revoked while your restricted license is in effect.

• We receive evidence that your reason for driving is no longer valid.

• We receive notification that your financial responsibility (SR-22) is cancelled.

• We receive notification that your ignition interlock device is no longer functioning or has been removed.

If you qualify for and are issued an ignition interlock license, you waive your right to a hearing or appeal.

RCW 46.20.308; 46.20.385; 46.20.391

We are committed to providing equal access to our services.

If you need accommodation, please call (360) 902-3900 or TTY (360) 664-0116.

DR-500-001 (R/8/12)WA

Form Dr-500-001 - Restricted Driver License Application

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