Form Dl-15 - Occupational Limited License (Oll) Petition Page 6
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6DL-15A (12-15)
SCHOOL DRIVING SCHEDULE
SCHOOL INFORMATION (S1)
Leave
Time
AM PM
Arrive
Time
AM PM
Mo Tu We Th Fr Sa Su
H
7:30
S1
8:00
4
4
4
4
4
4
EXAMPLE
(Complete additional affidavits if you attend more than one school)
S1
5:00
H
5:30
4
4
4
4
4
4
School Name _______________________________
Destination Codes
S1 = School
Address ____________________________________
S2 = School other
than S1
City ________________________________________
H = Home
State ________________ Zip __________________
Dean’s Name _________________________________
Detailed Explanation
D
Telephone Number of your Dean:
_______________________________________
SCHOOL ACKNOWLEDGMENT
I certify under penalty of law that all information given on this Affidavit is true and correct.
School Administrator Signature In Ink
Date
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]).
TREATMENT DRIVING SCHEDULE
Leave
Time
AM PM
MEDICAL TREATMENT INFORMATION
Arrive
Time
AM PM
Mo Tu We Th Fr Sa Su
H
7:30
T1
8:00
4
4
4
4
4
4
EXAMPLE
T1
5:00
H
5:30
4
Provider Name ______________________________
4
4
4
4
4
Destination Codes
Address ____________________________________
T1 = Treatment
H = Home
City ________________________________________
State ________________ Zip __________________
Contact Name ________________________________
Detailed Explanation
Telephone Number of Facility:
_______________________________________
E
MEDICAL PROVIDER ACKNOWLEDGMENT
I certify under penalty of law that all information given on this Affidavit is true and correct.
Date
Provider Signature In Ink
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]).
ADDITIONAL EXPLANATIONS
ACKNOWLEDGMENT
X
I certify under penalty of law that all information given on this Affidavit is true and correct.
SIGN
HERE
F
Applicant's Signature In Ink
Date
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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