Application For Texas Hardship Driver License

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APPLICATION FOR TEXAS HARDSHIP DRIVER LICENSE
The Texas Department of Public Safety may issue a driver license to a person who complies with the requirements for the Hardship License if
(1) the failure or refusal to issue the license will result in an unusual economic hardship for the family of the applicant, (2) the license is necessary
because of the illness of a member of the applicant’s family, or (3) a license is necessary because the applicant is enrolled in a vocational education
program and requires a driver’s license to participate in the program. The completion of an approved course in driver education is required.
Texas Transportation Code 521.223
NOTICE: All information on this application must be in INK. DPS CANNOT REFUND PAYMENT ONCE APPLICATION IS SUBMITTED.
Applications held only 90 days.
APPLICANT INFORMATION
CONTACT INFORMATION
LAST NAME:
HOME PHONE:
FIRST NAME:
OTHER PHONE:
EMAIL:
MIDDLE NAME:
ADDRESS INFORMATION
SUFFIX:
RESIDENCE ADDRESS:
MAIDEN NAME:
DATE OF BIRTH (mm/dd/yyyy):
CITY:
STATE:
SSN:
ZIP CODE:
COUNTY:
SEX: (Circle One)
MALE
FEMALE
MAILING ADDRESS:
EYE COLOR:
HAIR COLOR:
RACE / ETHNICITY:
(I) American Indian /Alaska Native
CITY:
STATE:
(A) Asian / Pacific Islander (B) Black (H) Hispanic (O) Other (W) White
ZIP CODE:
COUNTY:
HEIGHT: ft.
in.
WEIGHT: lbs.
PLACE OF BIRTH: CITY:
COUNTY:
STATE:
COUNTRY:
FATHER’S LAST NAME:
MOTHER’S MAIDEN NAME:
APPLICANT IS APPLYING FOR A HARDSHIP DRIVER LICENSE UNDER THE FOLLOWING PROVISION(S):
1. An unusual economic hardship on the family of the minor.
2. A death-related emergency:
Name of Deceased
Date of Death
Relationship to Deceased
3. Sickness or illness or disability of family members (PHYSICIAN’S STATEMENT REQUIRED)
Name of Family Member
Relationship
Family Physician
Phone Number (
)
4. Enrollment in a Vocational Education Program (CERTIFICATION FROM SCHOOL REQUIRED)
School
Phone Number (
)
Address of School
City
Time Classes Start
End
Days: MON
TUES
WED
THUR
FRI
OTHER
ADDITIONAL INFORMATION
Does the minor have a Texas Learner License or Provisional?
NO
YES
If YES, Learner / Provisional License #
Has the minor ever applied for a Hardship Driver License?
NO
YES
Where?
Has the minor completed an approved driver education course?
NO
YES
Classroom
, Driving
, or Both
FATHER’S NAME
License Number
Employed by
Address
Work Hours:
Work Phone (
)
MOTHER’S NAME
License Number
Employed by
Address
Work Hours:
Work Phone (
)
List all other members of the household: (Use extra page if necessary.)
Name
License #
Relationship
Name
License #
Relationship
Name
License #
Relationship
DL-77 (Rev. 1/14)
APPLICATION CONTINUED ON BACK

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