How To Apply For A Limited Driving Privilege As A Participant Of The Jasper County Dwi Court (Page 3 of 3) in pdf

How To Apply For A Limited Driving Privilege As A Participant Of The Jasper County Dwi Court Page 3

Name (Last, First, Middle):

Date of Birth (MM/DD/YYYY)

Driver License Number

Social Security Number

Street Address (no PO BOX)

City, State, Zip Code

Email Address

Alternate Address (if any)

Phone Number with Area Code:

Message Phone Number with Area Code:

Reasons Applicant is requesting a limited driving privilege for the following reason(s): (Must select at least one box)

Employment (Must provide name and address of employer(s) or if self-employed, name and address of business and

type of employment.)

_______________________________________________________________________________________________

Education (Must provide the school(s) name and address.)

_______________________________________________________________________________________________

Substance abuse treatment and/or community support meetings (Provide name and address of alcohol or drug

treatment program, if known.)

_______________________________________________________________________________________________

To and from all Court ordered requirements including community service and the courthouse

To and from a certified ignition interlock device (IID) service facility

Seeking medical treatment

Being unable to operate a motor vehicle will result in a hardship to the applicant because traveling is required

To transport child(ren) to and from child care and/or school (Must provide each child’s name, DOB, childcare or

school, childcare or school address)

_______________________________________________________________________________________________

To transport child(ren) to and from spousal or guardian visitation (Must provide address of visitation and name/DOB

of child if not listed above.)

_______________________________________________________________________________________________

To and from probation officer meetings

To and from bank (bank name and address) ___________________________________________________________

To and from church (church name and address)________________________________________________________

To and from grocery store

To and from gas station

To seek employment between 8 a.m. through 5 p.m.

To and from pharmacy

To and from other (Must Specify) ____________________________________________________________________

Applicant’s Signature

Date of Application (MM/DD/YYYY)

How To Apply For A Limited Driving Privilege As A Participant Of The Jasper County Dwi Court Page 3