Form Dl-15 - Occupational Limited License (Oll) Petition Page 5
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6DL-15A (12-15)
LIMITED LICENSE AFFIDAVIT
FOR LAW ENFORCEMENT OFFICIALS:
This Affidavit allows this person to drive the vehicle(s)
listed during the stated times for work, school, or medical treatment. in conjunction with an Occupational
Limited License and under section 1553 of the PA Vehicle Code.
CARRY THIS AFFIDAVIT WITH YOUR LIMITED LICENSE AT ALL TIMES.
DRIVER INFORMATION (Type or print information)
JR.,ETC.
FIRST NAME
MIDDLE NAME
LAST NAME
A
DATE OF BIRTH (must be listed)
LICENSE NUMBER
LICENSE EXPIRATION DATE
MONTH
DAY
YEAR
MONTH
DAY
YEAR
ZIP CODE
STATE
CURRENT STREET ADDRESS A Post Office Box number may be used in addition to the actual residence
CITY
address, but cannot be used as the only address.
VEHICLE INFORMATION
Year
Make
Model
License Plate Number
State
1.
2.
3.
4.
5.
VEHICLE INSURANCE INFORMATION
B
Insurance Company Name
Policy Number
Effective Date
Expiration Date
1.
2.
3.
4.
5.
DRIVING SCHEDULE INSTRUCTIONS
List your daily driving schedule. If you have a routine driving schedule, complete the chart(s) using the Destination Codes listed to the left of the chart.
If you do not have a routine driving schedule due to your job duties (such as salespersons, delivery and truck drivers), explain the territory or area you
drive, along with the days and hours you work. For both routine and non-routine schedules, include a detailed explanation of your need for an OLL
on the lines marked Detailed Explanation.
WORK DRIVING SCHEDULE
EMPLOYER INFORMATION (W1)
Leave
Time
AM PM
Arrive
Time
AM PM
Mo Tu We Th Fr Sa Su
H
7:30
W1
8:00
4
4
4
4
4
4
EXAMPLE
W1
5:00
H
5:30
4
4
4
4
4
4
(Complete additional affidavits if you have more than one job.)
Destination Codes
P
Company Name ______________________________
W1 = Primary Job
W2 = Second Job
W3 = Third Job
Address _____________________________________
H = Home
City _________________________________________
C
State ________________ Zip ___________________
Detailed Explanation
Supervisor's Name_____________________________
EMPLOYER ACKNOWLEDGMENT
Telephone Number of your immediate Supervisor:
I certify under penalty of law that all information given on this Affidavit is true and correct.
_______________________________________
Employer Signature in ink
Date
Self Employed: ❒ Yes ❒ No
WARNING: Misstatement of fact is a misdemeanor of the third degree punishable by a fine of up to $2,500 and/or
imprisonment up to one year (18 Pa C.S., Section 4904[b]).
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