Fill and Sign the My Drivers License Has Been Suspended or Denied for an Offense Which Makes Me Eligible for a Restricted Form

APPLICATION FOR RESTRICTED DRIVER’S LICENSE Case No. .......................................................................... Commonwealth of Virginia [ ] General District Court ................................................................................................................................................................... [ ] Juvenile & Domestic Relations District Court CITY/COUNTY ..................................................................................................................... ......... ........................................................................................................................ DEFENDANT DRIVER’S LICENSE NUMBER STATE ..................................................................................................................... ......... ........................................................................................................................ ADDRESS DATE OF BIRTH ..................................................................................................................... ......... ........................................................................................................................ CITY STATE ZIP DATE OF OFFENSE ..................................................................................................................... TELEPHONE NUMBER My driver’s license has been suspended or denied for an offense which makes me eligible for a restricted driver’s license; therefore, I request that the court gran t a restricted driver’s license for travel to and from the following locations for the following purpose(s): (Court use only) APPROVED (a) [ ] Travel to and from primary job Name and Location of Employer: ................................................................................................................................................ ..................................................................................................................................................................................................................... Days of Week: ............................................................................................................................................................................ Leave Home: .................................... Arrive at Work: ........................................ Leave Work: ..................................... . Arrive at Home: ....................................... [ ] YES [ ] NO [ ] Travel to and from secondary job Name and Location of Employer: ................................................................................................................................................ ..................................................................................................................................................................................................................... Days of Week: ............................................................................................................................................................................ Leave Home: .................................... Arrive at Work: ........................................ Leave Work: ..................................... Arrive at Home: ....................................... [ ] YES [ ] NO (b) [ ] Travel to and from VASAP [ ] YES [ ] NO (c) [ ] Travel during work hours only as required by my employer: Hours of required travel : ......................................................................................................................................................... [ ] YES [ ] NO Written verification must be carried [ ] YES [ ] NO (d) [ ] Travel to and from school Name and Location of school: ...................................................................................................................................................... Days of Week: ............................................................................................................................................................................ Leave Home: .................................... Arrive at School: ...................................... Leave School: .................................. Arrive at Home: ....................................... [ ] YES [ ] NO (e) [ ] Medically necessary travel for: [ ] me [ ] my elderly parent [ ] a person residing in my household ...................................................................... If for elderly parent or another person: Medical provider name: .......................................................................... Location: ....................................................................................................... [ ] YES [ ] NO (f-1) Ignition Interlock on any motor vehicle that you operate, if required. [ ] YES [ ] NO [ ] and on each motor vehicle owned by or registered to person (f-2) [ ] Travel to and from the facility that installed or monito rs the ignition interlock in the vehicle(s), if ignition interlock is ordered. [ ] YES [ ] NO (g-1) [ ] Necessary travel to transport a minor child(ren), who is/are under my care, to and from his/her/their school. Name and Location of School: ............................................................................................................................................. Dates and Times: ....................................................................................................................................................................... [ ] YES [ ] NO (g-2) [ ] Necessary travel to transport a minor child(ren), who is/are under my care, to and from day care Name and Location of Day Care Provider: ..................................................................................................................... Dates and Times: ....................................................................................................................................................................... [ ] YES [ ] NO (g-3) [ ] Necessary travel to transport a minor child(ren), who is/are under my care, to and from medical providers Name and Location of Medical Provider: ....................................................................................................................... Dates and Times: ....................................................................................................................................................................... [ ] YES [ ] NO NOTE: This is page one of a two-page form. FORM DC-263 (MASTER, PAGE ONE OF TWO) 10/13 Name .......................................................................................................................... Case No. ........................................................................................................... CONTINUED FROM PAGE 1 (h) [ ] Necessary travel for Court Ordered visitation with c hild(ren) Name(s): ........................................................................................................................................................................................ Location of Child(ren): ............................................................................................................................................................ Days and Times of Visitation: .............................................................................................................................................. [ ] YES [ ] NO (i-1) [ ] Travel to and from appointments with probation officer Name and Location of Probation entity .................................................................................................................................... [ ] YES [ ] NO (i-2) [ ] Travel to and from programs required by court o r as a condition of probation Program Name and Location: ..................................................................................................................................................... Program Name and Location: ..................................................................................................................................................... [ ] YES [ ] NO (j) [ ] Travel to and from a place of religious worship Name and Location of place of religious worship: ................................................................................................................ Day of Week (one day per week ): ...................................................................................................................................... Leave Home: ................................................ Arrive at place of religious worship: ............................................... Leave place of religious worship: ................................................. Arrive Home: .................................................... [ ] YES [ ] NO (k) [ ] Travel to and from appointments approved by the Division of Child Su pport Enforcement of the Department of Social Services as a requirement of participation in an administrative or court -ordered intensive case monitoring program for child support for which I wi ll have with me written proof of the appointment, including written proof of the date and time of the ap pointment. [ ] YES [ ] NO (m) [ ] Travel to and from jail to serve a jail sentence that is to be served on weekends or on nonconsecutive days. [ ] YES [ ] NO (n) [ ] Travel to and from a job interview for which I will have with me written proof from my potential employer of the date, time and location of the job interview. [ ] YES [ ] NO I certify that the above information is true and accurate, that my drivin g privileges are not revoked or suspended for any other reason, and that I have no other pending charges against me that have not been divulged to the court. I understand t hat a Restricted Driver’s License permits me to operate a motor vehicle under the conditions approved by the Cour t. I further understand that should I be found driving outside the restrictions of the Restricted Driver’s License, I may be subject to the imposition of previously suspended sente nces in this case and new criminal charges may be brought against me. ........................................................................ __________________________________________________________ DATE DEFENDANT’S SIGNATURE Reviewed and Appr oved as indicated: ........................................................................ __________________________________________________________ DATE JUDGE NOTE: This is page two of a two -page form FORM DC-263 (MASTER, PAGE TWO OF TWO) 07/17