DMV-21 (Revised 9/2018) pg. 1
Central Services & Records
Driver’s License Assessment Team
555 Wright Way
Carson City, Nevada 89711-0400
Phone: 775-684-4364 Option 2
Fax: 775-684-4829
RESTRICTED LICENSE INFORMATION
NRS 483.250, 483.2521, 483.267-280, 483.360, 483.464 and 483.490
A restricted license may be obtained for a variety of reasons.
Juveniles in certain rural areas who need to drive in order to attend school or to transport themselves or a family member to medical
appointments may apply for a restricted license.
Individuals who have had their license suspended or revoked and have served at least half of their withdrawal period may apply for
a restricted license to drive on the job or to/from work, school, grocery store, medical appointments or for court-ordered child
visitation.
NOTE: Effective October 1, 2018 - Individuals who have had their license suspended or revoked caused by driving under the
influence or failing to submit to evidentiary testing will not qualify for a restricted license and will have the option to reinstate their
driving privileges, as long as an Ignition Interlock Device has been installed on vehicles they operate.
Exceptions apply for child support suspensions and some juvenile suspensions. Please call the phone number listed above if any of
these exceptions pertain to you.
APPLICATION: A restricted license cannot be approved for commercial driving purposes, to seek employment, or for public
school students in Carson City, Clark, Douglas or Washoe Counties.
Complete all sections of the Application for Restricted License that pertain to you. Attach all required documents.
Drive to/from work or drive on the job: Your employer must complete certain information on the application. Self-employed
applicants must attach a copy of their business license or other acceptable document(s) to substantiate self-employment.
Workdays and hours are limited to a maximum of six (6) days per week, ten (10) hours per day.
Drive for medical purposes: A physician’s statement is required.
Drive to/from medical appointments or a grocery store: The “Verification of Need” affidavit must be completed by an unbiased
individual and signed in front of a DMV authorized representative.
Minor drive to/from school or work: School authorities and parents/guardians must complete certain sections.
SR-22: Proof of financial responsibility (SR-22 Certificate of Insurance) must be filed after any revocation and certain suspensions before
a restricted license will be issued. The SR-22 insurance must be in place for a continuous three (3) year period from the date your driving
privilege is reinstated.
TESTING & FEES: Applicants may be required to successfully complete written, vision, and drive examinations before a restricted license
is issued. A reinstatement fee may be required.
POINT VIOLATOR SUSPENSION: Per NAC 483.225, proof of completion or enrollment in an approved traffic safety course within the
past 6 months is required for individuals whose license was suspended due to a accumulation of demerit points as outlined in NRS
483.475.
DENIAL OF AN APPLICATION: A restricted license application will be denied if your license was suspended or revoked for any of the
following:
1. A financial responsibility, medical or failure to appear suspension
2. Certain driving record convictions within the past five (5) years
3. The third demerit point suspension within the past five (5) years
DMV-21 (Revised 9/2018) pg. 2
Central Services & Records
Driver’s License Assessment Team
555 Wright Way
Carson City, Nevada 89711-0400
Phone: 775-684-4364 Option 2
Fax: 775-684-4829
APPLICATION FOR RESTRICTED LICENSE
INSTRUCTIONS: Please type or print in black ink. Failure to complete all applicable sections will cause considerable
delay in processing your application. You will be notified by mail of your approval or denial and provided instructions on
how to pick up your license. Mail or fax this completed application to the DMV office noted above.
REQUEST TO DRIVE: To/from work To/from school For medical purposes
On the job for work-related purposes To/from grocery store
APPLICANT INFORMATION
Name _____________________________________________________________________________ Home Phone ________________________
Last First Middle
Residential Address ___________________________________________________________________ City/Zip ___________________________
Mailing Address (if different) __________________________________________________________ City/Zip ______________________________
County_______________ Driver’s License # ______________________ Social Security #_____________________Date of Birth _______________
Does a licensed driver (not applicant) reside in the household? Yes No If “Yes,” name: ________________________________________
Relationship to Applicant_________________________________________ Driver’s License #_________________________________________
DO YOU HAVE A COURT ORDER FOR THIS LICENSE? Yes No If “Yes,” attach a copy of the court order to this application.
If you are a male at least 18 and less than 26 years of age, would you like to register with the Selective Service? By registering, you remain eligible
for federal student loans, grants, job training benefits, most federal jobs and, if applicable, U.S. citizenship. If YES, initial here: _____
SECTION A: DRIVE TO/FROM WORK; DRIVE ON THE JOB FOR WORK-RELATED PURPOSES
This license is effective only for employment designated on this application.
Most direct route from home to work
Exact # miles from your home to work, via most direct route _________________________
Are you self-employed? Yes No If “Yes,” provide a copy of your business license or other substantial proof.
EMPLOYERS AND SELF-EMPLOYED APPLICANTS COMPLETE THE FOLLOWING:
Business name___________________________________________________________ Phone
Business address/city/zip
Days applicant works____________________________________________________ Exact hours: ____________am/pm to_____________am/pm
Applicant required to drive during work hours? Yes No If so, specify areas where applicant must drive (city, work yard, etc.)
VERIFICATION OF EMPLOYMENT (TO BE COMPLETED BY EMPLOYER)
I AM AUTHORIZED TO PROVIDE THE INFORMATION INDICATED ABOVE AND VERIFY THAT THE APPLICANT IS CURRENTLY EMPLOYED
WITH THIS BUSINESS. I FURTHER CERTIFY THAT I WILL NOTIFY THE NEVADA DMV IF THIS EMPLOYEE TERMINATES EMPLOYMENT.
Signature of Applicant’s Superior_____________________________________________________________________ Date
Print Name/Title
DMV-21 (Revised 9/2018) pg. 3
SECTION B: DRIVE TO/FROM GROCERY STORE
Name of grocery store____________________________________ Address
Most direct route from home to store
Exact # miles from your home to store, via most direct route _________________________
Specify 2 days per week for travel: (1)_________________ (2)________________________ Two hours: _________ am/pm to ___________am/pm
“Verification of Need” must be completed - see Section F, “AFFIDAVITS, VERIFICATIONS”
SECTION C: DRIVE TO/FROM MEDICAL APPOINTMENTS - MEDICAL HARDSHIP IN FAMILY
Name of household member with medical condition________________________________________ Person’s Social Security #
Nature of medical condition
Name of medical provider________________________________________________Phone #
Address of medical provider
Most direct route from home to medical provider
Exact # miles from your home to medical provider, via most direct route _________________________
Dates of medical appointments____________________________________ Time________________ am/pm (attach additional sheets if necessary)
Attach statement from medical provider, on provider’s letterhead and dated within the past thirty (30) days. Must include (1) description
of medical condition, (2) prescribed medications, (3) verification that medical condition renders person unable to operate a motor
vehicle, (4) whether medical condition is temporary or permanent, (5) if temporary, estimated time for recovery, (6) any recommended
restrictions. (NAC 483.266)
“Verification of Need” must be completed - see Section F, “AFFIDAVITS, VERIFICATIONS”
SECTION D: DRIVE TO/FROM SCHOOL
Per NRS 483.270, public school students from Carson City, Clark, Douglas and Washoe Counties are not eligible for a to/from school restricted license.
STUDENTS AGE 14-18: This license shall be issued for the current school year only and used exclusively for academic purposes, NOT
extracurricular activities. The route shall be travelled on scheduled school days only, no more than once daily. Do not exceed any posted speed
limit. You are not authorized to travel faster than 55 mph on any road.
If minor’s license was revoked or suspended under NRS 62, “Juvenile Justice,” attach certified copy of court order authorizing restricted driving
privileges to and from school and/or work.
If minor is employed and needs to drive to/from work, also complete Section A of this form.
If home is less than 2 miles from school and student cannot walk, must submit physician statement meeting criteria of NAC 483.267.
Why is it impossible or impractical to provide transportation for this student?
Most direct route from home to school
Exact # miles from your home to school, via most direct route _________________________
Specify days of week for travel _____________________________________________________ Hours: _________ am/pm to ___________am/pm
SCHOOL VERIFICATION (TO BE COMPLETED BY SCHOOL AUTHORITY)
School name___________________________________________________________________ Phone
Address
1. Is the student’s enrollment in this school based on an approved variance? Yes No
2. Does the school provide bus transportation or transportation for hire to the student’s residential area? Yes No
3. Dates of school semesters: (1st) Begins____________ Ends_____________ (2
nd
) Begins____________ Ends______________
4. Exact hours student attends school (exclude extracurricular activities) From _________________ am/pm to ___________________am/pm
THE UNDERSIGNED ATTESTS THAT THE INFORMATION PROVIDED IS ACCURATE ACCORDING TO SCHOOL RECORDS.
Signature ______________________________________________________________________________________ Date
Print Name/Title
SECTION E: DRIVE TO/FROM COURT-ORDERED CHILD VISITATION
Address where child(ren) reside, including city
Most direct route from home to school
Exact # miles from your home to child’s residence, via most direct route _________________________
Specify days of week for travel _____________________________________________________ Hours: _________ am/pm to ___________am/pm
Attach certified copy of court order authorizing restricted driving privileges to and from child visitation (NAC 483.252).
DMV-21 (Revised 9/2018) pg. 4
SECTION F: AFFIDAVITS, VERIFICATIONS: Complete this section only if you have completed sections B
or C
A Notary Public may verify any of the signatures below in place of a DMV representative (Notary statement and seal must be
attached).
VERIFICATION OF NEED. This verification must be completed by an unbiased person (neighbor, social worker, clergyman) not residing in the
household and signed before a person authorized to administer oaths (NRS 483.300).
Print name_________________________________________________________________________ Phone
Address/City/Zip
Relationship to applicant_________________________________
Explain applicant’s inability to obtain other method of transportation
Describe applicant’s or family member’s medical problems (if applicable)
Signature_______________________________________________________________ Date
Authorized DMV Representative________________________ Print name
APPLICANT AFFIDAVIT (TO BE SIGNED BY ALL APPLICANTS)
I UNDERSTAND THAT MY RESTRICTED LICENSE WILL BE CANCELLED BY THE DEPARTMENT IF:
1. I am convicted of a traffic violation which is assigned 4 or more demerit points.
2. My driving privilege is suspended, revoked or cancelled for any reason other than the reason I am applying for this license.
3. I fail to maintain proof of financial responsibility as required by NRS 485.307.
4. I fail to notify the DMV in writing whenever I change my address, employment or any other information included in this application within 10
days after the change occurs. I understand this change must be submitted to the same office where I am applying for this license. (NRS
483.240)
5. I fail to submit proof of completion or enrollment in an approved traffic safety school if required by NAC 483.225.
I certify under penalty of perjury that all statements made on this application are true and correct. I understand that any misstatement may cause
denial and/or cancellation of my restricted license, and that failure to comply with restrictions or any conditions of the restricted license may result in
cancellation of this privilege.
Applicant Signature_________________________________________________ Date
Authorized DMV Representative_____________________________________ Print name
PARENT/GUARDIAN AFFIDAVIT (TO BE COMPLETED AND SIGNED BY PARENT OR GUARDIAN OF MINOR APPLICANT)
Father’s/Guardian’s name______________________________________________________ Driver’s license #
Address______________________________________________________________________ Home phone
Employer’s name/address
Work days/hours_______________________________________________________________ Work phone
Mother’s/Guardian’s name______________________________________________________ Driver’s license #
Address______________________________________________________________________ Home phone
Employer’s name/address
Work days/hours_______________________________________________________________ Work Phone
I certify that I am the parent or guardian of the applicant and that all statements made on this application are correct. I understand that any misstatement
may cause denial and/or cancellation of the license. I accept liability for any neglect or willful misconduct by the minor and agree that failure of the
minor to comply with restrictions or any conditions of the restricted license may result in cancellation of this privilege.
Parent/Guardian Signature_______________________________________________________________ Date
Authorized DMV Representative_____________________________________ Print name
FOR DEPARTMENT USE: Verified ___________________________________________________ Date ____________________
SR-22: Needed Filed No Traffic Safety School: Yes No
PDPS: No Match LIC ELG NOT State ________ Number ___________________________________
Approved Denied Reason Denied ___________________________________________________________________________
Eligibility Date_______________ Expiration Date _________________ Restricted License No. __________________________________________
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