Request For Limited Driving Privileges - Mount Vernon Municipal Court
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2MOUNT VERNON MUNICIPAL COURT
REQUEST FOR LIMITED DRIVING PRIVILEGES
NAME: _______________________________________________________________________
ADDRESS: ____________________________________________________________________
HOME PHONE: __________________________ CELL: ________________________________
SOCIAL SECURITY NUMBER: ______________________________________________________
PLACE OF EMPLOYMENT: ________________________________________________________
ADDRESS OF EMPLOYMENT: _____________________________________________________
LIST BELOW YOUR WORK SCHEDULE, DAYS, HOURS, OVERTIME, AND ANY OTHER REASON YOU
ARE REQUESTING DRIVING PRIVILEGES:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
CHECK ALL THAT YOU ARE REQUESTING PRIVILEGES FOR:
PROBATION APPOINTMENTS
AA MEETINGS
FREEDOM CENTER
DRIVER INTERVENTION PROGRAM – PLACE & DATE: _______________________________
OTHER – EXPLAIN ___________________________________________________________
_____________________________________________________________________________
NAMES OF OTHER DRIVERS IN YOUR HOME _________________________________________
_____________________________________________________________________________
By signing this request for limited driving privileges, I affirm that I now have insurance or other
financial responsibility coverage and that I will not operate any motor vehicle without FR
coverage.
________________________________________
_____________________________
Signature
Date
**YOU MUST ATTACH A COPY OF YOUR MOST RECENT PAYSTUB WITH THIS REQUEST FOR
DRIVING PRIVILGES.
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Parent category: Legal