Form Di-28-Restricted Drivers License Petition-Bureau Of Motor Vehicles-Form
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1Department of the Secretary of State
Bureau of Motor Vehicles
WORK-RESTRICTED DRIVER’S LICENSE PETITION
Applies to Class C, Non-Commercial Driving Privileges Only
***You must submit your license and reinstatement fee(s) prior to consideration of your petition**
**This petition will not be considered unless fully completed**
ATTENTION: The time that you are driving on a work-restricted license will not count as suspension time if you are convicted or
adjudicated of the OUI offense.
Mail completed petition to:
Bureau of Motor Vehicles, OUI/HO Section
29 State House Station
Augusta, Maine, 04333-0029
Telephone #: 207-624-9000 Extension: 52104
NAME: ______________________________________________
DATE OF BIRTH: ________________ LICENSE #:________________
MAILING ADDRESS: _____________________________________________________________________________________________________
HOME TELEPHONE #: ________________________________
CELL #: _____________________________
SOCIAL SECURITY NUMBER DISCLOSURE STATEMENT
This statement is made in accordance with the Federal Privacy act of 1974, Section 7(b). Disclosure of your social security number is mandatory and is required by
29-A MRSA §1301 (5) and (6) to apply for or renew a driver’s license or non-driver identification card. Your social security number will be used solely for
administrative purposes and will be kept confidential.
Social Security Number: ________-_______-________
Note: If you have more than one employer, a separate petition must be completed for each employer. If you are self-employed, you must submit
information showing your self-employment, such as the names and numbers of any special licenses, business cards, business checks, business
letterhead, state or federal tax returns, seller’s or tax certificates, etc.
Are you licensed to operate in any other state? Yes ______ No ______
If yes, which state? ____________________________________
Are your privileges to operate a motor vehicle currently under suspension in any other state or province? Yes ______
No ______
If yes, which state or province?
_____________________________________________________________________________________________
Have you been convicted of OUI for the offense for which you are applying for a work restricted license? Yes ______
No ______
If yes, what was the date you were convicted? _________________________
Court where the OUI conviction occurred: _________________
Are you currently employed: Yes ________ No ________
Work Telephone #: ____________________________________
Name of Employer: _______________________________________________
Job title & Description: _________________________________
Address: ________________________________________________________
Driving time & distance to work: __________________________
Name & Title of your immediate supervisor: ____________________________________________________________________________________
Which days of the week do you work? _________________________________________________________________________________________
Work hours: Start ______________a.m./p.m.
End ___________ a.m./p.m.
Is driving, other than to and from work, part of your job? Yes ______ No ______
Additional work Information: ______________________________________________________________________________________________
WARNING: Making a false statement on this form is a criminal offense and may result in revocation of a restricted license. If you
commit any motor vehicle violations while in possession of a restricted license, or violate the restrictions imposed on your license,
your driving privileges will be suspended.
I hereby authorize the Secretary of State to contact my employer to confirm the above information.
Signature of Applicant: ______________________________________________________________
EMPLOYER VERIFICATION OF WORK STATEMENT
I verify that the above information is true and that I expect this employee to be employed by me for the immediate future.
Signature of Employer: _________________________________________________________
_____
DI-28 Rev. 10/2006
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