La Driver Permit Application Page 2
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2APPLICATION NOT VALID IF THIS SECTION NOT COMPLETED BY AUTHORIZED COMPANY REPRESENTATIVE
The only persons authorized to sign applications are those representatives who are identified on the “LADOT Signature Authorization Form,” which must be on file with the Department.
Company
________________________________________________________ DOT Code_________ Phone____________________ ext._____
Address____________________________________________________________ City __________________________ Zip Code___________
By ____________________________________________ ______________________________________________ Date___________________
Printed Name of Authorized Signatory
Original Signature
Applicant, you will be fingerprinted and your criminal history reviewed. Use this space to disclose all convictions; license suspensions or
revocations; mental or physical incapacities or infirmities; use of drugs or “pain killers” and, if prescribed by a physician, his/her name and address.
For criminal convictions, provide the date of conviction, description of crime, and degree (i.e., infraction, misdemeanor, or felony).
Example: 11/30/2010 – DUI – misdemeanor
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THIS SPACE BELOW IS RESERVED FOR OFFICIAL LADOT REPORT
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PERMIT DENIAL, CANCELLATION, OR REVOCATION
Date___________________
DENIED ____________________________________________________________________________________
Date___________________
CANCELLED ________________________________________________________________________________
Date___________________
REVOKED __________________________________________________________________________________
APPLICATIONS MUST BE TWO SIDED WITH ORIGINAL SIGNATURES
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