Form Occ-551-001 Occupational/restricted Driver License Application
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Occupational/Restricted
Driver License Application
RCW 46.20.391
For validation only. 106-040-254-0005
Eligibility information is on the next page
PRINT OR TYPE — Name of applicant (Last, First, Middle initial)
IIDL fee_______________Date received ______________
How would you like your license sent to you? (Check one only)
LSR initials________________Office no. ______________
US mail
email
Fax
Delivery information (Mailing address, email, or (Area code) Fax number
Date of birth
Driver license number
Social Security number
Mandatory for child support laws,
42 USC 666(a), RCW 26.23.150. Kept on file at DOL.
Used for identification, 42 USC 405.
Verification of Eligibility – This section must be completed by an authorized individual
Reason for driving
Select one reason only. A separate application must be completed for each reason.
Applicant needs to drive for:
Work, including self-employment, WorkFirst, apprenticeship, or on-the-job training.
Must be completed by employer, business owner, or a WorkFirst representative.
School. Must be completed by the school administrator/registrar.
Court-ordered community service. Must be completed by a representative of the court.
Substance abuse treatment/ 12-step meetings. Must be completed by the treatment provider or 12-step group leader.
Is transit service available?
Yes
No
Continuing healthcare for yourself. Must be completed by your healthcare provider.
Continuing care of a dependent. Must be completed by the applicant.
Name(s) of dependent(s) ____________________________________________________________________________
Relationship to dependent(s) _________________________________________________________________________
Statement of dependency and need for continuing care:
Enclose additional pages if needed. Insufficient explanation may result in a request for additional documents.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Required driving hours (Not over 12 hrs in a 24 hr period)
Days required
Geographical driving area (County or city)
am
am
From_______
To_______
S
M
T
W
T
F
S
pm
pm
If “Continuing care of a dependent” was selected as the reason above, skip to the “Applicant Declaration” section.
PRINT OR TYPE — Name and title of authorized individual completing this section
Name of organization (i.e. company, court, medical center, etc.)
UBI or business license number (Employers only)
Organization street address
City
State
ZIP code
(Area code) Telephone number
Signature of authorized individual completing this section
X
Date
Applicant Declaration
Applicant signature
I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
X
Date and place
(Area code) Home telephone number
(Area code) Work telephone number
OCC-551-001 (R/12/08)W Page 1 of 2
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Parent category: Legal