Application For Limited Driving Privileges - Chillicothe Municipal Court, Ohio Page 2
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3IN THE CHILLICOTHE M UNICIPAL COURT, OHIO
APPLICATION FOR LIMITED DRIVING PRIVILEGES.
Name:______________________________ SSN:_____________________________ DOB:______________________________
Home Address:_________________________City:_________________________________State/zip:________________________
Court Case No:______________________________________ Offense:________________________________________________
ALS - Date: _____________ D r i ve r ' s Li c e ns e # ___ ______ __
Check one:
Court Suspension - Date ______________
Check all that apply:
OCCUPATIONAL:
Name of Business:____________________________________________________________________________________
Address of Business:__________________________________________________________________________________
W ork days and hours:_________________________________________________________________________________
Are you required to work overtime?
YES
NO
If YES, when?_____________________________________________
Do you work at a location other than the business address?
YES
NO
If YES, address of work:_______________________________________________________________________________
Are you required to drive a
Company vehicle or
Personal vehicle in connection with your job?
YES
NO.
If YES, explain: _____________________________________________________________________________________
EDUCATIONAL:
Name of School:______________________________________________________________________________________
Address of school:_____________________________________________________________________________________
Scheduled days and times of classes:______________________________________________________________________
___________________________________________________________________________________________________
YOU MUST CARRY YOUR CLASS SCHEDULE W ITH YOU.
VOCATIONAL: List all job related activities:____________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
MEDICAL:
Name of Doctor: ______________________________________________________________________________________
Address: ____________________________________________________________________________________________
YOU MUST CARRY PROOF OF APPOINTMENT, DOCTOR’ S ORDER OR PRESCRIPTION.
LICENSE EXAMINATION: You may drive in conjunction with taking a driver’s examination.
YOU MUST CARRY A COPY OF APPOINTMENT NOTICE W ITH YOU.
COURT ORDERED TREATMENT(S): You may drive to/from AA individual counseling sessions, weekend intervention
programs, or other programs.
Name of Program:__________________________________________________________________________________
Address:__________________________________________________________________________________________
Days and hours:____________________________________________________________________________________
____________________________________ __(______)______________________
Complete phone number
Signature
Revised 3/15
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