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
(c) [ ] Travel during work hours only as required by my employer:
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
Re
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