Fillable VA Application For Restricted License APPLICATION FOR RESTRICTED

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VA Application For Restricted License APPLICATION FOR RESTRICTED

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U.S.A. forms for City of Lynchburg, VA - Department of Information Technology

BROWSE CITY OF LYNCHBURG, VA - DEPARTMENT OF INFORMATION TECHNOLOGY (VA) FORMS

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APPLICATION FOR RESTRICTED DRIVER’S LICENSE Case No. ..........................................................................

Commonwealth of Virginia

[ ] General District Court

................................................................................................................................................................... [ ] Juvenile & Domestic Relations District Court

CITY/COUNTY

..................................................................................................................... .................................................................................................................................

DEFENDANT DRIVER’S LICENSE NUMBER STATE

..................................................................................................................... .................................................................................................................................

ADDRESS DATE OF BIRTH

..................................................................................................................... .................................................................................................................................

CITY STATE ZIP DATE OF OFFENSE

.....................................................................................................................

TELEPHONE NUMBER

My driver’s license has been suspended or denied for an offense which makes me eligible for a restricted

driver’s license; therefore, I request that the court grant a restricted driver’s license for travel to and from the

following locations for the following purpose(s):

(Court use only)

APPROVED

(a) [ ] Travel to and from primary job

Name and Location of Employer: ................................................................................................................................................

Days of Week: ............................................................................................................................................................................

Leave Home: .................................... Arrive at Work: ........................................

Leave Work: ...................................... Arrive at Home: .......................................

[ ] YES [ ] NO

[ ] Travel to and from secondary job

Name and Location of Employer: ................................................................................................................................................

Days of Week: ............................................................................................................................................................................

Leave Home: .................................... Arrive at Work: ........................................

Leave Work: ..................................... Arrive at Home: .......................................

[ ] YES [ ] NO

(b) [ ] Travel to and from VASAP [ ] YES [ ] NO

Hours of required travel: .........................................................................................................................................................

[ ] YES [ ] NO

Written verification must be carried

[ ] YES [ ] NO

(d) [ ] Travel to and from school

Name and Location of school: ......................................................................................................................................................

Days of Week: ............................................................................................................................................................................

Leave Home: .................................... Arrive at School: ......................................

Leave School: .................................. Arrive at Home: .......................................

[ ] YES [ ] NO

(e) [ ] Medically necessary travel for: [ ] me [ ] my elderly parent

[ ] a person residing in my household ......................................................................

If for elderly parent or another person: Medical provider name: ..........................................................................

Location: .......................................................................................................

[ ] YES [ ] NO

(f-1) Ignition Interlock on any motor vehicle that you operate, if required.

[ ] YES [ ] NO

[ ] and on each

motor vehicle

owned by or

registered to person

(f-2) [ ] Travel to and from the facility that installed or monitors the ignition interlock in the vehicle(s), if ignition

interlock is ordered.

[ ] YES [ ] NO

(g-1) [ ] Necessary travel to transport a minor child(ren), who is/are under my care, to and from his/her/their school.

Name and Location of School: .............................................................................................................................................

Dates and Times: .......................................................................................................................................................................

[ ] YES [ ] NO

(g-2) [ ] Necessary travel to transport a minor child(ren), who is/are under my care, to and from day care

Name and Location of Day Care Provider: .....................................................................................................................

Dates and Times: .......................................................................................................................................................................

[ ] YES [ ] NO

(g-3) [ ] Necessary travel to transport a minor child(ren), who is/are under my care, to and from medical providers

Name and Location of Medical Provider: .......................................................................................................................

Dates and Times: .......................................................................................................................................................................

[ ] YES [ ] NO

NOTE: This is page one of a two-page form.

FORM DC-263 (MASTER, PAGE ONE OF TWO) 10/13

Clear All Data

Name .......................................................................................................................... Case No. ...........................................................................................................

CONTINUED FROM PAGE 1

(h)

[ ]

Necessary travel for Court Ordered visitation with child(ren)

Name(s): ........................................................................................................................................................................................

Location of Child(ren): ............................................................................................................................................................

Days and Times of Visitation: ..............................................................................................................................................

[ ] YES [ ] NO

(i-1) [ ] Travel to and from appointments with probation officer

Name and Location of Probation entity

....................................................................................................................................

[ ] YES [ ] NO

(i-2) [ ] Travel to and from programs required by court or as a condition of probation

Program Name and Location:

.....................................................................................................................................................

Program Name and Location: .....................................................................................................................................................

[ ] YES [ ] NO

(j) [ ] Travel to and from a place of religious worship

Name and Location of place of religious worship:

................................................................................................................

Day of Week (one day per week): ......................................................................................................................................

Leave Home: ................................................ Arrive at place of religious worship: ...............................................

Leave place of religious worship: ................................................. Arrive Home: ....................................................

[ ] YES [ ] NO

(k) [ ] Travel to and from appointments approved by the Division of Child Support Enforcement of the

Department of Social Services as a requirement of participation in an administrative or court-ordered

intensive case monitoring program for child support for which I will have with me written proof of the

appointment, including written proof of the date and time of the appointment.

[ ] YES [ ] NO

(m) [ ] Travel to and from jail to serve a jail sentence that is to be served on weekends or on nonconsecutive days. [ ] YES [ ] NO

(n) [ ] Travel to and from a job interview for which I will have with me written proof from my potential employer

of the date, time and location of the job interview.

[ ] YES [ ] NO

I certify that the above information is true and accurate, that my driving privileges are not revoked or suspended for any other reason, and

that I have no other pending charges against me that have not been divulged to the court. I understand that a Restricted Driver’s License

permits me to operate a motor vehicle under the conditions approved by the Court. I further understand that should I be found driving

outside the restrictions of the Restricted Driver’s License, I may be subject to the imposition of previously suspended sentences in this case

and new criminal charges may be brought against me.

........................................................................ __________________________________________________________

DATE DEFENDANT’S SIGNATURE

viewed and Approved as indicated:

........................................................................ __________________________________________________________

DATE JUDGE

NOTE: This is page two of a two-page form

FORM DC-263 (MASTER, PAGE TWO OF TWO) 07/17

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VA Application For Restricted License APPLICATION FOR RESTRICTED

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Completed 13 July 2020

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