Fill - Free fillable RESTRICTED LICENSE INFORMATION PDF form

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

) 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. __________________________________________

Fill Online, Printable, Fillable, Blank RESTRICTED LICENSE INFORMATION Form

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Fillable RESTRICTED LICENSE INFORMATION

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