Missouri Department Of Revenue Application For Limited Driving Privilege 4595 printable pdf download

Missouri Department of Revenue

Form

Application for Limited Driving Privilege

4595

Driver License Number

Date of Birth (MM/DD/YYYY)

___ ___ / ___ ___ / ___ ___ ___ ___

Name (Last, First, Middle Initial)

Social Security Number

Street Address (Do not use P.O. Box)

City, State, Zip Code

Mailing Address (If different from street address)

City, State, Zip Code

E-mail Address

Phone Number

___ ___ ___ ___ ___ ___ ___ ___ ___ ___

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.)

______________________________________________________

___________________________________________________________________________________________________________

Attending a Substance Abuse Traffic Offender Program (SATOP) (Provide name and address of alcohol or drug treatment

program, if known.)

___________________________________________________________________________________________

___________________________________________________________________________________________________________

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 and from child care (Must provide child care provider(s) name and address.)

____________________________________

___________________________________________________________________________________________________________

To and from bank (Must provide the name and address of the bank.)

_____________________________________________

___________________________________________________________________________________________________________

To transport child or children to and from school(s) (Must provide the school(s) name and address.)

__________________

___________________________________________________________________________________________________________

To transport child or children to and from spousal or guardian visitation (Must provide the address.)

__________________

___________________________________________________________________________________________________________

To and from probation officer meetings (Must provide the county where the meetings are held.)

_____________________

___________________________________________________________________________________________________________

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 court

To and from community service

The applicant must have proof of insurance (i.e., SR-22) on file with the Director of Revenue when submitting this application.

Proof of Ignition Interlock Device (IID) service or installation must also be provided if applicable.

Applicant’s Signature

Date of Application (MM/DD/YYYY)

___ ___ / ___ ___ / ___ ___ ___ ___

If the application is approved, an order granting the limited driving privilege will be mailed to you.

You must carry the original copy of the Limited Driving Privilege Notice with you when operating a motor vehicle.

Form 4595 (Revised 06-2013)

Mail to:

Driver License Bureau

Phone: (573) 526-2407

Visit

P.O. Box 200

Fax: (573) 522-8795

for additional information.

Jefferson City, MO 65105-0200

E-mail:

dlbmail@dor.mo.gov

Missouri Department Of Revenue Application For Limited Driving Privilege 4595

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