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
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.
Limited Driving Privilege Reasons
Applicant is requesting a limited driving privilege for the following reason(s): (Must select at least one box)
r Employment (Must provide name and address of employer(s) or if self-employed, name and address of business and type of
employment.) ______________________________________________________________________________________
__________________________________________________________________________________________________
r Education (Must provide the school(s) name and address.) ______________________________________________________
___________________________________________________________________________________________________________
r Attending a Substance Abuse Traffic Offender Program (SATOP) (Provide name and address of alcohol or drug treatment
program, if known.)
___________________________________________________________________________________________
___________________________________________________________________________________________________________
rTo and from a certified ignition interlock device (IID) service facility
rSeeking medical treatment
Being unable to operate a motor vehicle will result in a hardship to the applicant because traveling is required:
rTo and from child care (Must provide child care provider(s) name and address.)____________________________________
___________________________________________________________________________________________________________
rTo and from bank (Must provide the name and address of the bank.) _____________________________________________
___________________________________________________________________________________________________________
rTo transport child or children to and from school(s) (Must provide the school(s) name and address.) __________________
___________________________________________________________________________________________________________
rTo transport child or children to and from spousal or guardian visitation (Must provide the address.) __________________
___________________________________________________________________________________________________________
r OTHER ____________________________________________________________________________________________________
___________________________________________________________________________________________________________
rTo and from grocery store rTo and from gas station rTo seek employment
rTo and from pharmacy rTo and from court obligations rTo and from church
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)
___ ___ / ___ ___ / ___ ___ ___ ___
Sign
Mail to: Driver License Bureau Phone: (573) 526-2407
P.O. Box 200 Fax: (573) 522-8795
Jefferson City, MO 65105-0200 E-mail: dlbmail@dor.mo.gov
Visit http://dor.mo.gov/drivers/ldp.php
for additional information.
Form 4595 (Revised 02-2017)
(___ ___ ___)___ ___ ___-___ ___ ___ ___
Form
4595
Application for Limited Driving Privilege
