Fill and Sign the Third Offense Commonwealth of Virginia Form

FORM CC-1470 (MASTER, PAGE ONE OF TWO) 11/15 HEARING DATE AND TIME .................................................................... .................................................................... .................................................................... COMPLETE DATA BELOW IF KNOWN RACE SEX BORN HT. WGT. EYES HAIR MO. DAY YR. FT. IN. SSN: PETITION FOR RESTORATION OF DRIVING PRIVILEGE – Case No. ............................................................. THIRD OFFENSE COMMONWEALTH OF VIRGINIA ............................................................................................................ Circuit Court CITY OR COUNTY ............................................................................................................ PETITIONER’S NAME ............................................................................................................ ADDRESS ............................................................................................................ TO THE JUDGE OF THE ABOVE -NAMED COURT: I respectfully represent that on ................................................................ , my driver’s license was revoked by the Department of Motor DATE Vehicles, pursuant to Virginia Code § 46.2 -391 (B), based on the following convictions: ............................................................................................................................................................................................................................................................. OFFENSE OFFENSE DATE CONVICTION DATE CONVICTING COURT ............................................................................................................................................................................................................................................................. OFFENSE OFFENSE DATE CONVICTION DATE CONVICTING COURT ............................................................................................................................................................................................................................................................. OFFENSE OFFENSE DATE CONVICTION DATE CONVICTING COURT I have attached a certified transcript of my driving record from the Department of Motor Vehicles. CHECK A OR B BELOW TO INDICATE THE BASIS OF YOUR PETITION AND COMPLETE OTHER SEC TIONS AS APPLICABLE: [ ] A. Restoration under Va. Code § 46.2- 391(C)(1). (Eligible only after five (5) years from the date of the last conviction.) My license was revoked based on and dependent upon three convictions pursuant to Va. Code § 18.2- 266, § 18.2- 51.4 or Subsection A of § 46.2 -341.24 or valid local ordinance or law of another state or jurisdiction relating to operating a motor vehicle under the influence of intoxicants or drugs. I represent that: (i) At the time of my convictions, I was addicte d to or psychologically dependent on the use of alcohol or other drugs; and (ii) At this time, I am no longer addicted to or psychologically dependent on the use of alcohol or other drugs; and (iii) At least five years have passed from the date of the last conviction upon which the revocation of my license was based; and (iv) I do not constitute a threat to the safety and welfare of myself or others with respect to the operation of a motor vehicle. I request that the Court restore my privilege to operate a motor vehicle in the Commonwealth upon my evaluation by the Virginia Alcohol Safety Action Program. If the Court does not restore my privilege to operate a motor vehicle in the Commonwealth as requested above, I further request, as indicated by completin g the next section, that the Court authorize the issuance of a restricted license in lieu of restoring my privilege to drive as provided in Va. Code § 46.2- 391(C)(1). I request that the Court grant the restricted driver’s license for travel to and from th e following locations for the following purpose(s): Case N o. ............................................................. [ ] Travel to/from the facility that installed or monitors the ignition interlock on your vehicle(s) , if ignition interlock is ordered . [ ] Travel to/from work [ ] Travel to/from VASAP [ ] Travel during work [ ] Travel to/from school [ ] Travel to/from school for child [ ] Travel to/from day care for child [ ] Travel to/from medical service facility for [ ] you [ ] minor child [ ] elderly parent [ ] person residing in house hold: ...................................................................... [ ] Travel to/from court ordered visitation with child or children [ ] Travel to/from appointments with probation officer [ ] Travel to/from programs required by court or as a condition of probation [ ] Travel to/from a place of religious worship ........................................................................\ ................................................................................................\ .......................................................... NAME AND LOCATION OF PLACE OF WORSHIP ........................................................................\ ................................................................................................\ .......................................................... REQUESTED DAY OF WEEK AND TIME FOR TRAVEL [ ] Travel to/from appointments approved by the Division of Child Support Enforcement of the Department of Social Services as a requirement of participation in an adm inistrative or court-ordered intensive case monitoring program for child support [ ] Travel to/from jail to serve a sentence on weekends or nonconsecutive days [ ] Travel to/from a job interview for which you have with you written proof from your prospec tive employer of the date, time, and location of the job interview. ........................................................................\ ................................................................................................\ ..................................................................................... NAME AND ADDRES S OF EMPLOYER DAYS AND HOURS WORKED [ ] B. Restricted License under Va. Code § 46.2- 391(C)(2). (Eligible only after three (3) years from the date of your last convict ion.) My license was revoked based on and dependent upon three convictions pursuant to Va. Code § 18.2- 266, § 18.2- 51.4 or Subsection A of § 46.2 -341.24 or valid local ordinance or law of another state or jurisdiction relating to operating a motor vehicle under the influence of intoxicants or drugs. I represent that: (i) At the time of my convictions, I was addicted to or psychologically dependent on the use of alcohol or other drugs; and (ii) At this time I am no longer addicted to or psychologically depe ndent on the use of alcohol or other drugs; and (iii) At least three years have passed from the date of the last conviction upon which the revocation of my license is based; and (iv) I do not constitute a threat to the safety and welfare of myself or others with respect to the operation of a motor vehicle. I re quest that the Court order the issuance of a restricted license to allow me to drive to and from my home to the place of my employment, upon evaluation by the Virginia Alcohol Safety Action Program . ........................................................................\ ................................................................................................\ ..................................................................................... NAME AND ADDRES S OF EMPLOYER DAYS AND HOURS WORKED I request that the court hold a hearing on my petition. ........................................................................\ .................. ______________________________________________________________ DATE PETITIONER ’S SIGNATURE FORM CC-1470 (MASTER, PAGE TWO OF TWO) 07/17