Form Dmv-136 - Application For Restricted License Page 3
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4SECTION B: DRIVE TO/FROM GROCERY STORE
Name of grocery store____________________________________ Address
Most direct route from home to store
Exact # miles from your home to store, via most direct route _________________________
Specify 2 days per week for travel: (1)_________________ (2)_________________________ Two hours: _________ am/pm to ___________am/pm
“Verification of Need” must be completed - see Section F, “AFFIDAVITS, VERIFICATIONS”
SECTION C: DRIVE TO/FROM MEDICAL APPOINTMENTS - MEDICAL HARDSHIP IN FAMILY
Name of household member with medical condition________________________________________ Person’s Social Security #
Nature of medical condition
Name of medical provider________________________________________________Phone #
Address of medical provider
Most direct route from home to medical provider
Exact # miles from your home to medical provider, via most direct route _________________________
Dates of medical appointments______________________________________ Time_________________ am/pm (attach additional sheets if necessary)
Attach statement from medical provider, on provider’s letterhead and dated within the past thirty (30) days. Must include (1) description of
medical condition, (2) prescribed medications, (3) verification that medical condition renders person unable to operate a motor vehicle, (4)
whether medical condition is temporary or permanent, (5) if temporary, estimated time for recovery, (6) any recommended restrictions.
(NAC 483.266)
“Verification of Need” must be completed - see Section F, “AFFIDAVITS, VERIFICATIONS”
SECTION D: DRIVE TO/FROM SCHOOL
Per NRS 483.270, public school students from Carson City, Clark, Douglas and Washoe Counties are not eligible for a to/from school restricted license.
STUDENTS AGE 14-18: This license shall be issued for the current school year only and used exclusively for academic purposes, NOT
extracurricular activities. The route shall be travelled on scheduled school days only, no more than once daily. Do not exceed any posted speed
limit. You are not authorized to travel faster than 55 mph on any road.
If minor’s license was revoked or suspended under NRS 62, “Juvenile Justice,” attach certified copy of court order authorizing restricted driving
privileges to and from school and/or work.
If minor is employed and needs to drive to/from work, also complete Section A of this form.
If home is less than 2 miles from school and student cannot walk, must submit physician statement meeting criteria of NAC 483.267.
Why is it impossible or impractical to provide transportation for this student?
Most direct route from home to school
Exact # miles from your home to school, via most direct route _________________________
Specify days of week for travel _____________________________________________________ Hours: _________ am/pm to ___________am/pm
SCHOOL VERIFICATION (TO BE COMPLETED BY SCHOOL AUTHORITY)
School name___________________________________________________________________ Phone
Address
1.
Is the student’s enrollment in this school based on an approved variance?
Yes
No
2.
Does the school provide bus transportation or transportation for hire to the student’s residential area?
Yes
No
3.
Dates of school semesters: (1st) Begins____________ Ends_____________
(2
) Begins____________ Ends______________
nd
4.
Exact hours student attends school (exclude extracurricular activities)
From __________________ am/pm to ___________________am/pm
THE UNDERSIGNED ATTESTS THAT THE INFORMATION PROVIDED IS ACCURATE ACCORDING TO SCHOOL RECORDS.
Signature ______________________________________________________________________________________ Date
Print Name/Title
SECTION E: DRIVE TO/FROM COURT-ORDERED CHILD VISITATION
Address where child(ren) reside, including city
Most direct route from home to school
Exact # miles from your home to child’s residence, via most direct route _________________________
Specify days of week for travel _____________________________________________________ Hours: _________ am/pm to ___________am/pm
Attach certified copy of court order authorizing restricted driving privileges to and from child visitation (NAC 483.252).
DMV-21 (Rev.6/2015)
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