OFFICE OF THE SECRETARY OF STATE
DRIVER SERVICES DEPARTMENT
2701 South Dirksen Parkway • Springfield, Illinois 62723
WAIVER REQUEST
DATE OF REQUEST: ____________________________________________________________________________
NAME OF APPLICANT: ____________________________________________________________________________
ADDRESS: ____________________________________________________________________________________
CITY, STATE & ZIP CODE: ________________________________________________________________________
DRIVER’S LICENSE #: ____________________________________________________________________________
TELEPHONE NUMBER: __________________________________________________________________________
REASON FOR BREAK IN DRIVER’S LICENSE RECORD:
(To be completed by applicant. If more room is needed, attach extra paper. Attach any documentation to verify this
information i.e., doctor, hospital records, etc.)
Date Signature of Applicant
(When form has been completed, forward to the attention of the School Bus Safety Section at the above address.)
******************************************************************************************************************************************
OFFICIAL USE ONLY. DO NOT WRITE BELOW THIS LINE.
____ Based upon my review, the circumstances leading to the break in this applicant’s valid driver’s license record are
acceptable and a waiver is granted.
____ Based upon my review, the circumstances leading to the break in the applicant’s valid driver’s license record are
not acceptable and a waiver is not granted.
REMARKS:
Date Authorized Personnel Signature
Printed by authority of the State of Illinois. November 2013 —1—DSD SB 8.1
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
